Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6019_Библиотеки_им_академика_М_И_Перельмана.pdf
21 Percutaneous Spinal Fixation
257
Fig. 21.10 The owl’s eye image (right) is obtained by
starting with an AP image, adjusting the sagittal angle,
and centering on target vertebrae and then rotating the
on the L4 lamina just medial to the inferior L4
facet. On the AP image, the starting point is at the
junction of L4 lower endplate and the medial border of the L5 pedicle. The trajectory should aim
toward the lateral tip of the L5 lower endplate on
an AP image. On the lateral image, the trajectory
should aim for the anterior tip of the L5 lower endplate (Fig. 21.12). Once the trajectory has been set,
the Jamshidi needle can be replaced with guidewire or drill guide to establish the tract inside the
bone. Then the procedure is followed by a standard percutaneous technique, including a cannulated tap and screws over the guidewire.
Percutaneous Iliac Screws
Besides percutaneous lumbar pedicle and facet
screw, the technique of percutaneous iliac screw
is also described in this chapter. Fluoroscopy is
also used to perform percutaneous iliac screw
insertion. The key step is to obtain the “teardrop”
configuration on C-arm image. The body of the
ischium is visualized by angling the fluoroscope
in a “Ferguson” view in the sagittal plane and
coronal plane. This allowed for the “teardrop”
configuration of the ischial body to be used for
K-wire cannulation (Fig. 21.13). This teardrop
C-arm on the axial plane to align with the pedicle (α
(angle, left) (Adapted from Ref. [9])
shape is visualized when the projection of the
inner and outer tables of the ilium overlap both
medially and laterally. Therefore, targeting the
“teardrop” configuration provides a proper trajectory for percutaneous iliac screw placement.
The entry point should be located just ventral to
the posterior superior iliac spine to avoid hardware prominence. A drill is used to make a pilot
hole on the cortical bone. A Jamshidi needle is
then advanced with the tip of the needle kept
within “teardrop” configuration under fluoroscopic guidance. The tract created with Jamshidi
needle is exchanged with K-wire and followed by
placement of a cannulated awl, tap, and iliac
screw. Screw length and diameter are measured
and planned according to the preoperative CT
imaging.
Illustrative Case
History
A 70-year-old woman presented to our clinic
with a complicated 20-year spinal history with
chief complaint of progressively worsening lower
back and anterior thigh pain for 5 months. The
pain is bilateral; however, it is more severe on the
258
Fig. 21.11 Illustration
of mini-open technique
(Adapted from Ref.
10])
[
K.H.-k. Chang et al.
right side. Her leg pain is intermittent and can
cause her legs to go weak and “give out at times.”
This hinders her ability to stand and ambulate
normally. She has tried nonsteroidal antiinflammatory drugs (NSAIDs) and physical therapy with no relief of symptoms. She denies any
bladder or bowel dysfunction.
Her past surgical history is significant for
three previous lumbar surgeries: an L5–S1
laminectomy 22 years ago, a L4–L5 laminectomy 20 years ago, and L3–L4 decompression
and bilateral laminotomies 6 years ago.
Preoperative imaging demonstrated an L3–L4
grade 2 spondylolisthesis (Fig.
21.14a). The
decision was made to perform a L3–L4 rightsided minimally invasive transforaminal interbody fusion with intervertebral cage fixation
and posterior L3–L4 percutaneous
instrumentation.
Postoperatively she was noted to have signifi-
cant improvement in her leg pain and ambulation
21.14b, c).
(Fig.
21 Percutaneous Spinal Fixation
Fig. 21.12 The illustration of the trajectory for percutaneous facet screw on AP and lateral view (Adapted from Ref. [12])
259
• To obtain properly aligned bony structures and
avoid a distorted image, the fluoroscope should
be manipulated to a certain position and angle
in which the X-ray beam from the source lies
perpendicular to the vertebrae of interest.
• A true anteroposterior (AP) fluoroscopic
image is the first step and might be the most
useful image when performing K-wire cannulation for percutaneous spinal fixation.
• The tip of the needle can be placed laterally to
the lateral border of the pedicle shadow before
skin incision, in order to estimate an appropriate entry point for Jamshidi needles on the
skin under fluoroscopy.
• Jamshidi needles should dock on the junction
between the transverse process and the lateral
Fig. 21.13 The “teardrop” configuration (Adapted from
Ref. [13])
border of the facet joint in percutaneous pedicle screw placement.
• The length of the longest axis of lumbar pedi-
cle is approximately 2 cm.
Technical Pearls
• The tapping and the screw insertion should
follow the trajectory of the guidewire, in order
• The entire percutaneous screw placement process relies heavily on a series of intraoperative
fluoroscopic images. Satisfactory intraoperative fluoroscopic imaging is imperative for
successful percutaneous screw placement in
MIS surgery.
to avoid excessive bending of the guidewire
and possible breakage.
• The key factor of percutaneous iliac screw is to
obtain the “teardrop” configuration on C-arm
image and keep the cannulation and instrumentation procedure within the teardrop configuration.
260
K.H.-k. Chang et al.
Fig. 21.14 (a) Preoperative lateral standing X-ray of a patient with L3–L4 grade I spondylolisthesis. (b) Postoperative
lateral image status post L3–L4 MIS TLIF. The listhesis is almost completely reduced. (c) Postoperative AP image
Complications and Strategies for Avoidance
common PPS fixation complications include
screw misplacement, nerve root injury, and
instrumentation malfunction.
With the shift from open-pedicle screw fixation
toward PPS, fixation advantages include preservation of posterior musculature, decreased intraoperative blood loss, shorter operative time,
lower infection risk, decreased postoperative
pain, shorter rehabilitation time, and hospital
stay [14]. However, PPS fixation is associated
with its own complication profile. The most
The core limiting factor behind PPS fixation
is the minimal surgical visibility compromising
the identification of anatomic landmark grossly.
The fundamental and most common complication for PPS fixation is inaccurate screw
implants. Inaccurate placement can result in
reoperation, subsequent instability, hardware
malfunction, or neurologic sequelae like dura
21 Percutaneous Spinal Fixation
261
tear or nerve root injury. In some rare, yet severe,
cases, misplacements can cause major vascular
and visceral injury that can result in devastating
consequence as limb amputation or even death
[15]. A German study investigating PPS fixation
accuracy demonstrated that 27 of 408 (6.6%)
percutaneously placed screws were misplaced,
with 19 medial pedicle violations, 6 lateral cortical defects, and only 1 cranial and 1 caudal displacement. Two misplacements resulted in nerve
root injuries at levels L4 and L5 and required
open revision. The S1 level showed the highest
misplacement rate (12%) [16]. The L5 and sacral
level are known to be associated with the higher
rates of misplacement. This may be due to their
proximity to the posterior iliac crest often causing screws to deviate medially. The other cause
could be that the axis of L5 and S1 pedicle is
much more medialized and steep than the other
levels and the vertebral body tends to be more
like a triangle on the axial plane. Occasionally
an ideal AP image for the pedicle shadow at L5
or S1 is not feasible. In such cases, we recommend to start with a more lateral entry point and
aim at a more medialized angle. This maneuver
can prevent the screw from perforating the anterior wall of vertebral body as well as violating
the spinal canal at the same time. L5 or sacral
screw misplacement may also be avoided with
lateral sacral screw placement, although this
concurrently increases risk of injury to the lumbosacral trunk and internal iliac vein, thus making it an uncommon alternative [16].
The thoracic spine is a unique challenge for
PPS fixation. The T1–T7, pedicles are often
narrow, have varying angles, and decreased
space from the medial border of the pedicle to
the spinal cord [
17]. For thoracic PPS fixation,
physicians often use the “in-out-in” technique
which adopts a more lateral entry point for
screw placement in order to avoid a medial
breach [17]. Additional studies report differing
rates of accuracy, 6.7% of 104 were misplaced
screws with no neurologic deficits [
18] and
0.29% of 700 misplaced screws with one neurologic complication [4]. Accuracy rates rely
heavily on spine location (thoracic, lumbar, or
sacral), operator dependency, and the subse-
quent learning curve. Previous studies have
found that the majority of misplaced screws
were implanted in the trial’s initial patients,
attesting for the procedure’s steep learning
curve [4, 19]. Traversing this learning curve
can be more feasible through the use of cadaveric training and intraoperative training under a
physician competent in PPS [20].
Maintaining full control of the guidewire is
crucial throughout the whole procedure. Once the
guidewire is lost, it is difficult to re-cannulate.
Surgeons must control the guidewire while
manipulating the instrument along the wire. It is
also critical to follow the trajectory of the guidewire during instrumentation and assure the trajectory is parallel to the K-wire. Otherwise, the
K-wire may potentially break and then be
retained within the bone.
One of the drawbacks of PPS fixation is radiation exposure due to intraoperative fluoroscopy
and CT guidance. One study showed that PPS
was associated with an average of 54% more
radiation per pedicle screw compared to openpedicle screw fixation [21]. Recent advances in
CT computer navigation software aim to decrease
the physician radiation burden, only taking
images while the team is outside the operation
room. However, these new 3D fluoroscopy and
CT protocols depend on having specially
equipped ORs with trained staff. Though these
requirements initially increase the cost burden of
CT-navigated PPS cases a year offset these costs
by avoiding reoperations [22].
Facet joint and pedicle bone that are sclerotic
can be very difficult for the advancement and
cannulation of Jamshidi needles. Occasionally
the Jamshidi needles have to be replaced with
direct cannulation of the pedicle with a highspeed drill. The tip of the drill is docked on the
same entry point as a Jamshidi needle would
place. With careful advancement of the drilling
tip under X-ray monitoring, we will be able to
create an accessible pathway into sclerotic bone
21.15). The drill can then be removed and
(Fig.
replaced with Jamshidi needles or cannulated
pedicle probe. The remainder of the step is identical to usual PPS procedures.
262
Fig. 21.15 (a) The drill is carefully controlled under X-ray monitoring and used to advance into sclerotic bone. (b) The
trajectory of the drill is identical to that of a usual Jamshidi needle under fluoroscopic image
K.H.-k. Chang et al.
Other Considerations
Chapman et al. published a largest series of 1609
screws comparing the accuracy of PPS to openpedicle screws. It appeared that the breach rate
was lower with PPS. But the magnitude of
breach was worse once the PPS had a breach.
They reported the facet violation was similar
between both methods [23]. Kwan et al. published a study of pedicle screw placement for
cadaveric thoracic spine and concluded that the
accuracy of PPS and open screws were similar
[24]. This study concluded that the percutaneous
technique with fluoroscopy guidance was safe
and feasible for thoracic spine fixation. Most of
the existing studies support these results and
reinforce that PPS technique is safe and accurate
compared to the open alternative.
Superior facet violation has also been reported
with PPS. Superior facet violations may accelerate future adjacent segment degeneration [25,
26]. Some investigations suggest that poor visu-
alization of anatomical landmarks during PPSF
increases rates of facet violation reporting 12% in
PPS fixation versus 5% in open [27] and 8.5%
(PPS) versus 2% (open) for grade 3 violations,
respectively [
no difference in the incidence (18.18% vs.
28]. However, other studies show
18.72%, p = 0.62) [29, 30]. Some studies have
proposed that a high body mass index (BMI) is a
risk factor for facet violation.
With the increasing popularity of minimally
invasive procedures, the PPS technique has been
used for spinal deformity, often regarded as the
most difficult and high risk field in spine surgery,
even in the open setting. Wang et al. evaluated 400
percutaneous screws using fluoroscopy guidance in
a 5-year period with CAT scan, with a total breach
rate of 7.1%. Two percent of the screws had high
grade pedicle violation (>4 mm, either medial or
lateral). Only two screws, in two respective patients,
required revision. The overall rate of facet joint violation in this series was low (11.2%) compared to
other percutaneous series. The results from this
study demonstrated that the outcome and safety
profile of PPS is favorable for deformity patients.
However, more studies are required to reinforce this
evidence of percutaneous screws for deformity [6].
3D image guide is another common option for
percutaneous screws. The new technology of
O-arm-guided screw placement provides surgeons with three-dimensional images, offering a
clear perspective. During the procedure, the position of all the instruments is well presented in
axial, coronal, and sagittal views on the O-arm
monitor. Surgeons may feel more secure with
21 Percutaneous Spinal Fixation
263
comprehensive monitoring during the procedure.
The downside is that new technology requires
more OR space, expense, and trained personnel
and creates more radiation. It should also be
noted that the O-arm cannot provide real-time
image as C-arm fluoroscopy does. During the
step of tapping and screw insertion along the
K-wire, the surgeon is not able to track the trajectory of the instrumentation and make sure it is
parallel to that of the K-wire without fluoroscopic
shots. There is some evidence showing that
O-arm navigation can improve the accuracy and
decrease superior facet violations for percutaneous screws [30, 31]. One study investigated accuracy of CT vs. fluoroscopy, with 96.4% vs. 93.9%
accuracy for in the lumbar spine and 95.5% vs.
79.0% in thoracic spine [32]. Meta-analysis studies also support these findings [33, 34].
Another emerging technology has been robotassisted spine surgery. The surgical robot is able
to assist surgeons in both open and percutaneous
settings. Preoperative thin-cut CT image is
uploaded into the robot software and used for presurgical planning for screw placement. During the
surgery, the robot “arm” can rotate and indicate a
desirable trajectory according to the preoperative
planning. Guidewire is used for cannulation with
the trajectory provided, followed by tapping and
screw insertion as the usual percutaneous technique. Early investigations suggest that robotassisted methods are able to achieve excellent
accuracy of percutaneous screw placement and
reduce the radiation exposure [35, 36].
Conclusion
With the ubiquity of the minimally invasive spinal
surgery, percutaneous spinal fixation has become
a fundamental skill set. It is important for spinal
surgeons to familiarize themselves with these percutaneous spinal instrumentation techniques.
Among all of the methods, percutaneous lumbar
pedicle screws remain the most popular and reliable procedure under fluoroscopic guidance. As
with all new technologies, percutaneous spinal
fixation will continue to evolve and become more
precise and efficient over time.
References
1. Kabins MB, Weinstein JN. The history of vertebral screw and pedicle screw fixation. Iowa Orthop
J. 1991;11:127–36.
2. Foley KT, Gupta SK. Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical results.
J Neurosurg. 2002;97(1 Suppl):7–12.
3. McAnany SJ, Overley SC, Kim JS, Baird EO, Qureshi
SA, Anderson PA. Open versus minimally invasive
fixation techniques for thoracolumbar trauma: a metaanalysis. Global Spine J. 2016;6(2):186–94.
4. Mobbs RJ, Sivabalan P, Li J. Technique, challenges
and indications for percutaneous pedicle screw fixation. J Clin Neurosci. 2011;18(6):741–9.
5. Rosen DS, Ferguson SD, Ogden AT, Huo D, Fessler
RG. Obesity and self-reported outcome after
minimally invasive lumbar spinal fusion surgery.
Neurosurgery. 2008;63(5):956–60. discussion 960
6. Ahmad FU, Wang MY. Use of anteroposterior view
fluoroscopy for targeting percutaneous pedicle screws
in cases of spinal deformity with axial rotation.
J Neurosurg Spine. 2014;21(5):826–32.
7. Wang MY, Pineiro G, Mummaneni PV. Stimulusevoked electromyography testing of percutaneous
pedicle screws for the detection of pedicle breaches:
a clinical study of 409 screws in 93 patients.
J Neurosurg Spine. 2010;13(5):600–5.
8. Wiesner L, Kothe R, Ruther W. Anatomic evaluation of two different techniques for the percutaneous
insertion of pedicle screws in the lumbar spine. Spine
(Phila Pa 1976). 1999;24(15):1599–603.
9. Yoshida G, Sato K, Kanemura T, Iwase T, Togawa D,
Matsuyama Y. Accuracy of percutaneous lumbosacral
pedicle screw placement using the oblique fluoroscopic view based on computed tomography evaluations. Asian Spine J. 2016;10(4):630–8.
10. Pakzaban P. Modified mini-open transforaminal lumbar interbody fusion: description of surgical technique
and assessment of free-hand pedicle screw insertion.
Spine (Phila Pa 1976). 2016;41(18):E1124–30.
11. Dhall SS, Wang MY, Mummaneni PV. Clinical and
radiographic comparison of mini-open transforaminal lumbar interbody fusion with open transforaminal
lumbar interbody fusion in 42 patients with long-term
follow-up. J Neurosurg Spine. 2008;9(6):560–5.
12. Chin KR, Seale J, Cumming V. Mini-open or percutaneous bilateral lumbar transfacet pedicle screw
fixation: a technical note. J Spinal Disord Tech.
2015;28(2):61–5.
13. Wang MY, Williams S, Mummaneni PV, Sherman
JD. Minimally Invasive Percutaneous Iliac Screws:
Initial 24 Case Experiences With CT Confirmation.
Clin Spine Surg. 2016;29(5):E222–5.
14. Court C, Vincent C. Percutaneous fixation of thoracolumbar fractures: current concepts. Orthop Traumatol
Surg Res: OTSR. 2012;98(8):900–9.
15. Lopera JE, Restrepo CS, Gonzales A, Trimmer CK,
Arko F. Aortoiliac vascular injuries after misplacement of fixation screws. J Trauma. 2010;69(4):870–5.
264
K.H.-k. Chang et al.
16. Wiesner L, Kothe R, Schulitz KP, Ruther W. Clinical
evaluation and computed tomography scan analysis
of screw tracts after percutaneous insertion of pedicle
screws in the lumbar spine. Spine. 2000;25(5):615–21.
17. Puvanesarajah V, Liauw JA, Lo S-F, Lina IA, Witham
TF. Techniques and accuracy of thoracolumbar pedicle
screw placement. World J Orthop. 2014;5(2):112–23.
18. Ni WF, Huang YX, Chi YL, et al. Percutaneous
pedicle screw fixation for neurologic intact thoracolumbar burst fractures. J Spinal Disord Tech.
2010;23(8):530–7.
19. Sclafani JA, Kim CW. Complications associated with
the initial learning curve of minimally invasive spine
surgery: a systematic review. Clin Orthop Relat Res.
2014;472(6):1711–7.
20. Voyadzis J-M. The learning curve in minimally invasive spine surgery. Semin Spine Surg.
2011;23(1):9–13.
21. Wild MH, Glees M, Plieschnegger C, Wenda K. Fiveyear follow-up examination after purely minimally
invasive posterior stabilization of thoracolumbar fractures: a comparison of minimally invasive percutaneously and conventionally open treated patients. Arch
Orthop Trauma Surg. 2007;127(5):335–43.
22. Dea N, Fisher CG, Batke J, et al. Economic evaluation
comparing intraoperative cone beam CT-based navigation and conventional fluoroscopy for the placement
of spinal pedicle screws: a patient-level data costeffectiveness analysis. Spine J. 2016;16(1):23–31.
23. Chapman TM, Blizzard DJ, Brown CR. CT accuracy of percutaneous versus open pedicle screw
techniques: a series of 1609 screws. Eur Spine
J. 2016;25(6):1781–6.
24. Kwan MK, Chiu CK, Lee CK, Chan CY. Comparison
between percutaneous fluoroscopic-guided and conventional open pedicle screw placement techniques
for the thoracic spine: a safety evaluation in human
cadavers. Bone Joint J. 2015;97-B(11):1555–61.
25. Babu R, Park JG, Mehta AI, et al. Comparison of
superior-level facet joint violations during open and
percutaneous pedicle screw placement. Neurosurgery.
2012;71(5):962–70.
26. Lau D, Terman SW, Patel R, La Marca F, Park P. Incidence
of and risk factors for superior facet violation in minimally invasive versus open pedicle screw placement
during transforaminal lumbar interbody fusion: a comparative analysis. J Neurosurg Spine. 2013;18(4):356–61.
27. Jones-Quaidoo SM, Djurasovic M, Owens RK,
Carreon LY. Superior articulating facet violation: percutaneous versus open techniques. J Neurosurg Spine.
2013;18(6):593–7.
28. Babu R, Park JG, Mehta AI, et al. Comparison of
superior level facet joint violations during open and
percutaneous pedicle screw placement. Neurosurgery.
2012;71(5):962–70.
29. Wang L, Wang Y, Yu B, Li Z, Li Y. Comparison of
cranial facet joint violation rate between percutaneous
and open pedicle screw placement: a systematic review
and meta-analysis. Medicine. 2015;94(5):e504.
30. Yson SC, Sembrano JN, Sanders PC, Santos ER,
Ledonio CG, Polly DW Jr. Comparison of cranial
facet joint violation rates between open and percutaneous pedicle screw placement using intraoperative
3-D CT (O-arm) computer navigation. Spine (Phila
Pa 1976). 2013;38(4):E251–8.
31. Ohba T, Ebata S, Fujita K, Sato H, Haro
H. Percutaneous pedicle screw placements: accuracy
and rates of cranial facet joint violation using conventional fluoroscopy compared with intraoperative
three-dimensional computed tomography computer
navigation. Eur Spine J. 2016;25(6):1775–80.
32. Waschke A, Walter J, Duenisch P, Reichart R, Kalff
R, Ewald C. CT-navigation versus fluoroscopy-guided
placement of pedicle screws at the thoracolumbar
spine: single center experience of 4,500 screws. Eur
Spine J. 2013;22(3):654–60.
33. Tian NF, Huang QS, Zhou P, et al. Pedicle screw
insertion accuracy with different assisted methods: a
systematic review and meta-analysis of comparative
studies. Eur Spine J. 2011;20(6):846–59.
34. Kosmopoulos V, Schizas C. Pedicle screw placement
accuracy: a meta-analysis. Spine (Phila Pa 1976).
2007;32(3):E111–20.
35. Kantelhardt SR, Martinez R, Baerwinkel S, Burger R,
Giese A, Rohde V. Perioperative course and accuracy
of screw positioning in conventional, open roboticguided and percutaneous robotic-guided, pedicle
screw placement. Eur Spine J. 2011;20(6):860–8.
36. Schatlo B, Molliqaj G, Cuvinciuc V, Kotowski M,
Schaller K, Tessitore E. Safety and accuracy of robotassisted versus fluoroscopy-guided pedicle screw
insertion for degenerative diseases of the lumbar
spine: a matched cohort comparison. J Neurosurg
Spine. 2014;20(6):636–43.
Lumbar Osteotomy Techniques
Ryan Nazar, Jeffrey Gum, John Dimar,
and Mladen Djurasovic
Introduction
Adult spinal deformity is becoming increasingly
common in our aging US population [1]. In addition to degenerative etiologies, iatrogenic sagittal
malalignment complications are more common
with the increase in lumbar fusion procedures
being performed. The critical goal in the surgical
treatment of the adult deformity patient is twofold: (1) restoration of anatomic alignment and
(2) preservation of function.
Sagittal balance and overall global spinal
alignment have been shown to be one of the
most important factors associated with improvement in patient outcomes following adult deformity surgery [2]. In the past decade, studies
have found that restoration of normal or nearnormal spinopelvic parameters correlates
closely with health-related quality of life
(HRQOL) and pain measures in both deformity
R. Nazar, MD
Department of Neurological Surgery, University of
Louisville, Louisville, KY, USA
e-mail:
Ryan.gregory.nazar@gmail.com
J. Gum, MD • J. Dimar, MD
M. Djurasovic, MD (*)
Norton Leatherman Spine Center, Department of
Orthopaedic Surgery, University of Louisville,
Louisville, KY, USA
e-mail:
djuraso@hotmail.com
22
and degenerative patients [3]. Although coronal
alignment has not been as important as sagittal
alignment, fusing the spine such that the torso is
balanced over the pelvis within the cone of
economy in both planes does allow better global
balance of the spine and is seen as an optimal
goal [4]. Fusion of the spine with significant
residual coronal or sagittal malalignment can
place excessive stresses through both the instrumented segments and non- instrumented segments of the spine contributing to additional
degeneration, instrumentation failure, and progression of the malalignment [5, 6].
In this chapter, we will review modern surgical corrective techniques for spinal deformity
focusing on lumbar osteotomies that can be utilized to improve sagittal and coronal alignment
and restore global spinal alignment in the adult
patient. The origins of these techniques will be
briefly reviewed to help frame and appreciate the
advancement of correction methodology that has
occurred. Utilizing the best available evidence,
we then will review the indications and patient
selection as a first step and also discuss the
decision- making process and preoperative planning. Lastly, we detail the surgical technique of
the most common osteotomy types with emphasis on complication avoidance. Although variations exist, three general categories of osteotomy
have been described: (1) posterior column osteotomy (PCO), (2) pedicle subtraction osteotomy
(PSO), and (3) vertebral column resection (VCR).
© Springer International Publishing AG 2017
L.T. Holly, P.A. Anderson (eds.), Essentials of Spinal Stabilization,
DOI 10.1007/978-3-319-59713-3_22
265
266
R. Nazar et al.
More recently, the Schwab classification describes
six anatomically defined osteotomies that are
commonly accepted and used [
7].
History
The surgical techniques for restoration of spinal
alignment continue to evolve (Fig. 22.1). The
posterior column osteotomy (PCO) includes
both the Smith-Petersen osteotomy (SPO) and
the Ponte osteotomy. In 1945, Smith-Petersen
et al. described a posterior extension or chevrontype osteotomy combined with anterior osteoclasis for single-level correction of kyphosis in
the setting of ankylosing spondylitis [8]. The
Smith-Petersen osteotomy involves bilateral
removal of the facet joints or fusion mass allowing the spine to pivot along the middle column
increasing segmental lordosis and causing an
extension in length of the anterior column [9]. In
modern practice, the SPO is usually performed
across multiple segments for correction of a
multi-segmental deformity [10]. The osteotomies can be performed asymmetrically to allow
for some degree of coronal plane correction [11].
Because SPO requires lengthening of the anterior
column, the patient must have a mobile anterior
disc in theory; thus, it cannot be optimally effective across a fully ankylosed segment.
The Ponte-type osteotomy was first described
by Ponte et al. in 1984 for Scheuermann kyphosis
and is described as segmental osteotomies followed by posterior decompression along unfused
regions of kyphotic deformity [12]. Although
today the terms Smith-Petersen osteotomy and
Ponte osteotomy are used interchangeably, the
modern technique more closely resembles the
procedure described by Alberto Ponte. In fact,
these osteotomies have also become a mainstay
in correction of coronal plane deformities, such
as in adolescent idiopathic scoliosis.
Pedicle subtraction osteotomy (PSO) was
first introduced by Thomasen in 1985 [13]. The
PSO has further been referred to as a transpedicular wedge procedure, wedge osteotomy, and
eggshell osteotomy. PSO has found widespread
use for fixed, angular sagittal plane deformity
resulting from multiple etiologies [14]. Like
vertebral column resection (VCR), PSO has
been associated with significant perioperative
complications; however, modern advancements
‘48. Cobb. Cobb Measurement.‘73. Vauzelle. Wake up test.
‘45. Smith-Peterson. Smith
Peterson Osteotomy (SPO).
1900
‘70. Roy-Camile and
Judet. Pedicle screw
technology.
‘85. Thomasen. Pedicle Subtraction
CT Evolved.
‘30 ‘50 ‘70 ‘80 ‘90 ‘05 ‘10
‘22. MacLennan.
Vertebral Column
Resection (VCR).
‘11. Hibbs. First Surgical
Correction of Scoliosis in
America.
‘55. Allan. “Jack”
Instrumentation
System.
‘77. Nash, SSEPs. ‘84 Cotrel and Dubouset.
‘62. Harrington.
Distraction System.
‘82. Steffee. Pedicle
screw use in
thoracic spine.
Fig. 22.1 Evolution of lumbar spinal osteotomies
Osteotomy (PSO).
MRI Evolved.
Segmental distraction and
compression.
‘82. Luque.
Segmental
instrumentation and
crosslink.
‘06. Ondra. Asymmetric
‘87. Bradford.
Circumferential VCR.
2000
‘84. Ponte. Ponte
Osteotomy.
‘04. Lee. Direct vertebral
‘07. Tamaki. MEPs.
Osteotomies.
‘05. Suk.
Posterior only
VCR
rotation.
‘08. Voyadzis. MIS and Hybrid Techniques.
‘14. Schwab. Classification
of Osteotomies.
‘10. Fujibayashi.
Computer assisted
spinal osteotomies.
‘10,13. Akbar and Aurouer.
Computer modeling and pre-
op planning.