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Procedure 28 | Osteotomy Techniques (Smith-Petersen and Pedicle Subtraction) for Fixed Sagittal Imbalance 279
S T E P 5
I N S T RU M E N T A T I O N /
I M P L AN TAT IO N
• The rods should be strong, but not
“too” stiff. The authors prefer 5.5-mm
stainless steel.
• Use of a third rod across the PSO site
can assist in closure of the osteotomy
without placing excessive force on the
pedicle screws. This rod can be left in
place as an additional fixation anchor
across the osteotomy.
P O S T OP E R AT IV E P E A R L S
• If the osteotomies are securely closed,
either centrally and/or along the lateral
masses, then usually a rapid
mobilization of the patient is possible.
• If the osteotomies do not completely
close, then it may be necessary to
secondarily perform an anterior
operation to facilitate fusion and load
sharing.
P O S T OP E R AT IV E P I T F A L L S
• With both procedures, there is some
risk of neurologic deficit. This risk is
greater with a pedicle subtraction
procedure. The deficit is not always
predicted by spinal cord monitoring; so,
a Stagnara wake-up test is advisable.
Bridwell KH, Lewis SJ, Lenke LG, Baldus C, Blanke K. Pedicle subtraction
osteotomy for the treatment of fixed sagittal imbalance. J Bone Joint Surg Am
2003;85:454-63.
Pedicle subtraction osteotomies have a role in patients with fixed sagittal
imbalance following idiopathic scoliosis surgery, following distal degenerative
lumbar spine surgery, and also for posttraumatic kyphosis and ankylosing
spondylitis patients. Most patients receive substantial benefit from these
procedures.
Buchowski JM, Bridwell KH, Lenke LG, et al. Neurological complications of lumbar
pedicle subtraction osteotomy: a 10-year assessment. Spine 2007;32:2245-52.
A review of 108 pedicle subtraction osteotomies revealed an intraoperative and
postoperative neurologic deficit rate of 11.1%, with 2.8% of deficits being
permanent.
Cho K, Bridwell KH, Lenke LG, Berra A, Baldus C. Comparison of Smith-Petersen
versus pedicle subtraction osteotomy for the correction of fixed sagittal
imbalance. Spine 2005;30:2030-37.
Three Smith-Petersen osteotomies accomplish approximately what is
accomplished with one pedicle subtraction procedure. The blood loss is greater
with a pedicle subtraction procedure.
Lagrone MO, Bradford DS, Moe JH, et al. Treatment of symptomatic flatback after
spinal fusion. J Bone Joint Surg Am 1988;70:569-80.
Smith-Petersen osteotomies are useful in treating fixed sagittal imbalance
syndromes occurring after idiopathic scoliosis surgeries performed many years
prior.
Rose PS, Bridwell KH, Lenke LG, et al. Role of pelvic incidence, thoracic kyphosis,
and patient factors on sagittal plane correction following pedicle subtraction
osteotomy. Spine 2009;34:785-91.
Pelvic incidence and thoracic kyphosis can predict the lumbar lordosis necessary
to correct sagittal imbalance with a pedicle subtraction osteotomy.
Voos K, Boachie-Adjei O, Rawlins BA. Multiple vertebral osteotomies in the
treatment of rigid adult spine deformities. Spine 2001;26:526-33.
Multiple Smith-Petersen osteotomies are useful in treating rigid adult
deformities. Frequently, both anterior and posterior surgeries are required.
Yang BP, Ondra SL, Chen LA, et al. Clinical and radiographic outcomes of thoracic
and lumbar pedicle subtraction osteotomy for fixed sagittal imbalance.
J Neurosurg Spine 2006;5:9-17.
For sagittal plane deformities, radiographic and clinical outcomes are superior
for pedicle subtraction osteotomy performed in the lumbar spine rather than
the thoracic spine.
P O S T OP E R AT IV E
C O N T RO V E R S IE S
• There is some potential for the patient
to add on to the kyphosis, either
proximally or distally. There is also
potential for pullout of the fixation
points above and below, and therein,
additional deformity can be created.
P R O C ED U R E 2 9
Spondylolysis Repair
Manish K. Kasliwal, Brian Walsh, Ernest Found,
and Vincent C. Traynelis
I N D I CAT I O NS P E A R L S
• Young healthy patients with normal
sagittal alignment, no significant
instability, and a positive bone scan
who have failed to improve with a
course of nonoperative management
are the best candidates for this
procedure.
T R E A T M E N T OP T I O N S
• Arthrodesis with or without
instrumentation
• Direct screw fixation of defect
P O S I TI O N I N G PE A R L S
• Strive to position patient in normal
lumbar lordosis. This is best
accomplished by extending the hips.
P O S I TI O N I N G PI T FA L L S
• Avoid significant lumbar flexion.
Although this may facilitate the surgical
exposure, it is not associated with
optimal postoperative sagittal balance
or outcome.
P O S I TI O N I N G EQ U I P M EN T
• Jackson table, laminectomy rolls
Indications
n
Pars defect must be source of pain
n
No instability on imaging
n
Minimal disk degeneration present
n
Patient 30 years of age or younger
n
Nonsmoker
Examination/Imaging
n
Anteroposterior and lateral lumbar radiographs
n
Flexion and extension lateral lumbar radiographs (Figure 29-1, A and B)
n
Lumbosacral computed tomography (Figure 29-2)
n
Bone scan
Surgical Anatomy
n
The affected lamina
n
The affected pars interarticularis
n
The pedicle of the affected vertebra
Positioning
n
Prone on Wilson frame, laminectomy rolls, or Jackson table
Portals/Exposures
n
A standard posterior lumbar exposure is used to access the affected vertebra.
The lamina, facets, and proximal transverse process should be exposed (Buck,
1970; Askar, 2003; Chung, 2007; Debusscher, 2007).
n
Recently, minimally invasive techniques of repair have been described using
percutaneous screws and of tubular retractors (Nichol, 1986; Morscher, 1988).
S T E P 1 P EA R L S
• A small curette or cutting burr may be
used for this step. Great care should
be exerted to avoid excessive bone
removal. If the defect is large, an
autologous bone graft should be
placed.
• Do not aggressively dissect the facet
joint capsule.
Procedure
Step 1
n
Curettage of the pars defect is performed.
n
A burr is used to freshen fracture surfaces (Figure 29-3). Note that the burr and
exposure of the defect margins are enlarged in Figure 29-3 to illustrate the
technique. The actual débridement should disrupt as little bone as possible.
n
The soft tissue between the fracture surfaces is removed (Figure 29-4).
Procedure 29 | Spondylolysis Repair 281
A
FIGURE 29-1, A-B
FIGURE 29-2
B
FIGURE 29-3
282 Procedure 29 | Spondylolysis Repair
FIGURE 29-4
A
FIGURE 29-5, A-B
S T E P 2
I N S T RU M E N T A T I O N /
I M P L AN TAT IO N
• Pedicle screw
• Cable
S T E P 2 P EA R L S
• The pars defect should be inspected
carefully while tightening the cable.
Once the cable is tight, the fracture
edges should be well approximated
(Figure 29-6, A and B).
B
Step 2
n
A pedicle screw with a hole through its post is inserted using standard
techniques.
n
A cable is threaded through the hole in the pedicle screw post and around the
spinous process (Figure 29-5, A and B).
Procedure 29 | Spondylolysis Repair 283
A
FIGURE 29-6, A-B
S T E P 3 P IT FA L L S
• Care should be taken to avoid superior
distraction of the lamina, which may
result in suboptimal fracture alignment.
S T E P 3
I N S T RU M E N T A T I O N /
I M P L AN TAT IO N
• Pedicle screw
• Sublaminar hook
B
FIGURE 29-7
Step 3
n
An alternative technique uses a hook/rod construct (Figure 29-7).
n
A pedicle screw is inserted using standard techniques.
n
A sublaminar hook is placed, connected to the pedicle screw with a rod, and
secured after compression force is applied.
n
Minimal access techniques can be used to perform the same.
Postoperative Care and Expected Outcomes
n
A camp brace is used for 6 weeks.
284 Procedure 29 | Spondylolysis Repair
Evidence
Askar Z, Wardlaw D, Koti M. Scott wiring for direct repair of lumbar spondylolysis.
Spine 2003;28:354-7.
Grade B description of the Scott wiring technique in 14 patients.
Buck JE. Direct repair of the defect in spondylolisthesis: preliminary report. J Bone
Joint Surg Br 1970;52:432-7.
Grade B description of a direct screw fixation technique across the pars defect.
Chung CH, Chiu HM, Wang SJ, Hsu SY, Wei YS. Direct repair of multiple levels of
lumbar spondylolysis by pedicle screw laminar hook and bone grafting: clinical,
CT, and MRI-assessed study. J Spinal Disord Tech 2007;20:399-402.
Grade B prospective study of ten patients with multiple-level lumbar
spondylolysis treated with segmental pedicle screw hook fixation and
autogenous bone graft. Follow-up confirmed a union rate of 75% (18 pars/
24 pars) on CT scans.
Debusscher F, Troussel S. Direct repair of defects in lumbar spondylolysis with
a new pedicle screw hook fixation: clinical, functional and CT-assessed study.
Eur Spine J 2007;16:1650-8.
Grade B study of 23 patients who were treated with a pedicle hook and screw
system with good clinical outcome in 20, and 91% fusion rate as assessed on a
CT scan.
Morscher E, Gerber B, Fasel J. Surgical treatment of spondylolisthesis by bone
grafting and direct stabilization of spondylolysis by means of a hook screw.
Arch Orthop Trauma Surg 1988;103:178-88.
Grade B description of a hook screw fixation technique in 12 patients, 10 of
whom had an excellent or good outcome.
Nichol RO, Scott JHS. Lytic spondylolysis repair by wiring. Spine 1986;11:1027-30.
Grade C retrospective review of a wiring technique.
Noggle JC, Sciubba DM, Samdani AF, et al. Minimally invasive direct repair of
lumbar spondylolysis with a pedicle screw and hook construct. Neurosurg Focus
2008;25:E15.
Grade B review of minimally invasive pedicle screw and hook-rod technique in
five patients.
Sairyo K, Sakai T, Yasui N. Minimally invasive technique for direct repair of pars
interarticularis defects in adults using a percutaneous pedicle screw and
hook-rod system. J Neurosurg Spine 2009;10:492-5.
Grade C description of minimally invasive direct spondylolysis repair in two
adults.
Songer MN, Rovin R. Repair of the pars interarticularis defect with a cable-screw
construct: a preliminary report. Spine 1998;23:263-9.
Grade B report with an excellent description of the technique. The outcomes of
seven patients are retrospectively reviewed.
Tokuhasi Y, Matsuzaki H. Repair of defects in spondylolysis by segmental pedicular
screw hook fixation: a preliminary report. Spine 1996;21:2041-5.
Grade B report of six patients treated with a screw-hook technique.
P R O C ED U R E 3 0
Surgical Treatment of
High-Grade
Spondylolisthesis
Frank L. Acosta, Jr., and Christopher P. Ames
I N D I CAT I O NS P I T F A L L S
• Asymptomatic deformity
• Well-controlled low back pain
• Radiculopathy from another source
T R E A T M E N T OP T I O N S
• Direct reduction/transforaminal lumbar
interbody fusion
• Gaines procedure
• Transsacral cage/screw
• Sacral dome osteotomy
Indications
n
Severe, refractory low back pain
n
Sagittal imbalance
n
Radiculopathy
n
Neurogenic claudication
Examination/Imaging
n
Lumbar radiograph (Figure 30-1)
n
Standing 36-inch scoliosis radiograph (Figure 30-2)
n
Lumbar computed tomography (CT) scan (Figure 30-3)
n
Lumbar magnetic resonance imaging (MRI) (Figure 30-4)
FIGURE 30-1
FIGURE 30-2
286 Procedure 30 | Surgical Treatment of High-Grade Spondylolisthesis
P O S I TI O N I N G PE A R L S
• Adequate padding of pressure points
• Jackson pads at level of iliac crest
• Can use towels to increase chest
elevation to augment lumbar lordosis
P O S I TI O N I N G PI T FA L L S
• Avoid using Wilson frame: creates
kyphosis
P O S I TI O N I N G EQ U I P M EN T
• Jackson table
• Mayfield head frame (optional)
P O RTA L S / E X P O S U R ES
P E A R LS
• Wide exposure of lamina and transverse
processes
FIGURE 30-3
P O RTA L S / E X P O S U R ES
P I T F A L L S
• Inadequate understanding of local
anatomy of listhesed segment
P O RTA L S / E X P O S U R ES
E Q U I PM E N T
• C-arm
• Neuromonitoring leads (motor evoked
potentials [MEPs] and somatosensory
evoked potentials [SSEPs])
• Intraoperative CT scanner
FIGURE 30-4
Procedure 30 | Surgical Treatment of High-Grade Spondylolisthesis 287
Surgical Anatomy
n
Thecal sac/lumbosacral nerve roots
n
Listhesed vertebral body
n
Ileum
n
Pedicles
Positioning
n
Prone on Jackson table
Portals/Exposures
n
Open exposure of posterior spine and bilateral transverse processes
n
Exposure of ileum
S T E P 1 P EA R L S
• Intraoperative CT navigation improves
pedicle screw accuracy, particularly at
listhesed segment.
• Pelvic fixation is required in most cases.
• Reduction screws are placed at listhesed
segment(s) if attempting direct
reduction.
S T E P 1 P IT FA L L S
• Misidentification of listhesed pedicle
and/or nerve root
S T E P 1
I N S T RU M E N T A T I O N /
I M P L AN TAT IO N
• Pedicle screws (reduction screws at
listhesed segment)
S T E P 2 P EA R L S
• Gentle retraction of thecal sac
• Use fluoroscopic guidance
Procedure
Step 1
n
Exposure of posterior spine and ileum
n
Placement of pedicle screws bilaterally
n
Bilateral placement of iliac screws
n
Laminectomy (as needed)
Step 2
n
Sacral dome osteotomy (Figure 30-5)
S T E P 2 P IT FA L L S
• Entrance into L5 vertebral body
• Entrance into abdominal cavity
S T E P 2
I N S T RU M E N T A T I O N /
I M P L AN TAT IO N
• Osteotome
FIGURE 30-5
288 Procedure 30 | Surgical Treatment of High-Grade Spondylolisthesis
S T E P 3 P EA R L S
• Slow, gentle reduction
S T E P 3 P IT FA L L S
• Overreduction
S T E P 3
I N S T RU M E N T A T I O N /
I M P L AN TAT IO N
• Reduction screws
• Persuader
Step 3
n
Reduction of listhesed segment(s) (Figure 30-6)
Step 4
n
Sacral reaming (for transsacral cage/screw) (Figure 30-7)
n
Transsacral cage/screw placement (Figure 30-8)
A
C
FIGURE 30-6, A-D
B
D