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36 Principles of Deformity Correction
495
incision and muscle dissection compared to a tra­ditional thoracoabdominal exposure. The anat­omy of the transpsoas exposure is variable, and the position of the lumbar plexus may preclude access to the disc spaces, especially at L4–L5. Spinal deformity significantly reduces the safe zone for a direct lateral approach to the lumbar spine [46]. Intraoperative nerve monitoring is useful in identifying motor nerves, but direct visualization is important to minimize risk to sensory nerves including the ilioinguinal and the genitofemoral nerves. Nerve injury may be due to direct injury or to retraction against a fixed transverse process.

Posterior-Based Osteotomies

Posterior-based osteotomies encompass a spec­trum of techniques that enable effective correc­tion of mobile and rigid spinal deformities. Posterior-based osteotomies may be used in com­bination with an anterior approach in severe sag­ittal or coronal deformities. The spectrum of posterior-based osteotomies can be divided into six different grades, as described by Schwab and colleagues [47], or six different types as described by Berven and Bradford [48]. The six types are a continuum with each type building upon the bony removal performed in its predecessor. Because the bone resection is sequential, from facet resec­tion to transpedicular resections and corpecto­mies, the surgeon may often find that facet resections alone yield adequate correction or progress to a three-column osteotomy if the spine is more rigid. Figure 36.5 illustrates the spectrum of osteotomies from posterior-based facet resec­tions to vertebral column resection.
Types 1 and 2 (Complete Facet Resection)
Type 1 and 2 osteotomies both involve a com­plete facetectomy bilaterally at a given level. They involve resection of the posterior elements from the mid pars above to the pedicle below, including removal of the interspinous ligaments and ligamentum flavum. The osteotomy is then closed by compressing posteriorly. Ponte (type 1)
and Smith-Petersen (type 2) osteotomies are commonly used terms that fall under this cate­gory. There are important distinctions between the two. The Ponte osteotomy as originally described is characterized by deformity correc­tion through a non-fused disc space anteriorly. The osteotomy uses an axis of rotation at the cen­ter of the vertebra, with distraction of the anterior longitudinal ligament and posterior compression to realign a mobile spine [ the anterior longitudinal ligament determines the amount of correction that may be achieved at a single segment. In contrast, Smith-Petersen oste­otomy is performed at a level with a fused disc space, and correction is gained by osteoclasis of the anterior column with a center axis of rotation at the posterior longitudinal ligament and ante­rior column opening [50]. Type 1 osteotomies can achieve on average 5–10º of correction per level in a mobile disc level; type 2 osteotomies may yield up to 30º in patients with a Smith­Peterson approach [49, 51].
49]. The elasticity of
Types 3 and 4 (Pedicle Subtraction Osteotomies)
Type 3 and 4 osteotomies build upon the poste­rior element resection performed in type 2 to include resection of the pedicles bilaterally at a given level with an intraosseous partial resec­tion of the vertebral body. Heinig described the eggshell osteotomy in which the surgeon decan­cellates the vertebral body from a transpedicu­lar approach and then achieves correction of the spine with a controlled fracture of the decancel­lated vertebral body [ the transpedicular wedge resection osteotomy in which correction of deformity is gained through resection of a wedge of pedicle and vertebral body, followed by closure of the wedge. The posterior and middle portions of the index vertebral body are resected while the anterior vertebral cortex is left intact. The ful­crum for closure of the osteotomy is the supe­rior one-third of the vertebral body. This results in shortening of the posterior column without lengthening of the anterior column [ and 4 osteotomies are best applied in the lum­bar spine for rigid deformities with fused disc
52]. Thomasen described
53]. Type 3
496
J.N. Orina and S.H. Berven
Fig. 36.5 Spectrum of posterior-based osteotomies. Reprinted with permission from Berven S, Mummaneni P. Lumbar pedicle subtraction osteotomy. In: Zdeblick T, Albert T, editors. The Spine. Master Techniques in Orthopaedic Surgery. Third ed. Philadelphia: Lippincott Williams & Wilkins; 2014. p. 258
TABLE 20-1 Spectrum of Posterior-Based Osteotomies
Type Description Diagram Reference
1 Resection of posterior elements from
mid-pars above to pedicle below with realignment of the spine through hinging through a mobile disc anteriorly
2 Resection of posterior elements from
mid-pars above to pedicle below with realignment of the spine through hinging hinging through the anterior column of the spine which is ankylosed. The opening involves osteoclasis rather than movement through a mobile intervertebral disc
3 Posterior-based transpedicular
decancellation of the vertebral body with realignment through controlled fracture of the anterior column
Ponte
Smith-Peterson
Heinig
4 Posterior-based intraosseous wedge resection
of the vertebral body with realignment through osteoclasis of the proximal third of the anterior vertebral body
5 Posterior-based wedge resection with extension
of the osteotomy into the supraadjacent disc and realignment hinging on the anterior column at the intervertebral space
6 Posterior-based vertebral column resection
including one or more vertebra with adjacent discs
spaces. Although it can also be performed in the cervical or thoracic spine, the amount of sagittal correction achieved from this technique is greatest the more distally in the spine it is
Thomasen
Modified Thomasen
Suk
done based upon the distance of the osteotomy from C7 (i.e., an L4 pedicle subtraction osteot­omy leads to greater sagittal correction than an L1 pedicle subtraction osteotomy). Pedicle sub-
36 Principles of Deformity Correction
497
traction osteotomy can achieve between 25 and 35º of correction depending on the location in the spine at which it is performed [
54].
Type 5 (Extended Pedicle Subtraction Osteotomy)
Type 5 involves a pedicle subtraction osteotomy with wider wedge resection of the vertebral body, its superior endplate, and resection of the supra­adjacent disc. An interbody spacer can be placed into the supra-adjacent disc space to facilitate arthrodesis and prevent shortening of the anterior and posterior spinal column. The extended pedi­cle subtraction osteotomy is useful to gain a cir­cumferential fusion at the level of a three-column osteotomy with an open disc above the osteot­omy. Figure 36.6 demonstrates the stages of an extended PSO. The patient is a 62-year-old male with flatback deformity and sagittal plane malalignment following a prior L2-5 posterior instrumented fusion with TLIFs. Symptoms con­sisted of lower back pain and inability to stand upright. An L5-S1 ALIF followed by an extended PSO at L2 resulted in excellent correction of his sagittal plane deformity.
Type 6 (Vertebral Column Resection)
The type 6 osteotomy involves complete resec­tion of one or more vertebral bodies and the adja­cent superior and inferior intervertebral discs. Bradford described the vertebral column resec­tion from a combined anterior and posterior approach [55], and Suk described the posterior­based vertebral column resection [56]. This is a complex osteotomy that is reserved for rigid mul­tiplanar deformities and deformities involving translation of the trunk. In the thoracic spine, the osteotomy requires the surgeon to perform rib resection with a lateral extracavitary exposure of the vertebral body, often with sacrifice of exiting thoracic nerve roots and segmental vessels. The vertebral column resection results in circumfer­ential disconnection of the spine, leading to shortening of the anterior and posterior columns. An anterior cage may be placed to prevent severe shortening of the anterior column and to serve as a fulcrum for osteotomy closure.
Figure
36.7 demonstrates a type 6 vertebral
column resection. The patient is a 62-year-old
female with severe trunk translation above a prior fusion from L3 to S1. Traditional techniques of angular correction with segmental compression and distraction would be ineffective in correcting the deformity because compression of the con­vexity of the thoracolumbar curve would lead to increased trunk shift and compression of the con­vexity of the lumbosacral curve would increase shoulder asymmetry [
54]. In cases with severe
kyphosis and trunk shift, a vertebral column resection is most appropriate to facilitate transla­tion of the trunk relative to the pelvis.

Limited Versus Extensive Surgery

The surgical approach to spinal deformity is characterized by significant variability between providers. Surgical correction of spinal deformity may involve extensive surgeries with combined anterior and posterior approaches to the spine and complex osteotomies or more limited approaches to the deformity including decom­pression alone or decompression with a limited fusion. The appropriate approach to spinal defor­mity is the approach which maximizes benefit while limiting risk and costs of care [7]. Informed choice regarding an appropriate surgical approach requires consideration of the goals of care, patient preference, and surgeon preference [6]. A decom­pression alone may be appropriate in patients with primarily radicular pain and stable defor­mity, without progression of curvature and absent global sagittal or coronal malalignment [20]. A decompression with a limited fusion may be appropriate for patients with focal pain or neural compression that may require realignment of limited segments of the spine. Figure trates a case of a 32-year-old female with adult idiopathic scoliosis. Her deformity has not pro­gressed in the past 8 years, and she is well aligned in her global sagittal and coronal measures. She presents with limited left L4 and L5 radicular pain and significant lumbosacral pain. A limited decompression and fusion permit maintenance of mobility of the thoracolumbar spine and limited morbidity of the surgical approach. More exten­sive approaches to deformity including combined anterior and posterior approaches and multilevel
36.8 illus-
Fig. 36.6 62-year-old male with flatback deformity and sagittal malalignment following prior L2-5 posterior fusion
with transforaminal lumbar interbody fusion and inferior L2 to superior L5 laminectomies. (a) Preoperative AP
36 Principles of Deformity Correction
499
Fig. 36.7 A 62-year-old female with rightward trunk shift and progressive kyphosis above a prior limited L3–S1 spine fusion. A type 6 osteotomy with vertebral column resection at L1 and L2 faciliated translation of the trunk (without the loss of shoulder balance that may have
fusions may be most appropriate for patients in good health with severe symptomatic deformity that is progressive and involves global sagittal or coronal malalignment [20].

Technical Pearls

• Establishing the goals of surgery is a founda­tional principle in deformity correction. There is a correlation between radiographic measures
Fig. 36.6 (continued) scoliosis X-rays. (b) Preoperative lateral scoliosis X-rays. He has an SVA of + 20 cm. Pelvic incidence is 80 degrees and lumbar lordosis is 30 degrees, with a mismatch of 50 degrees between the two parameters. Pelvic tilt is 39 degrees indicating significant pelvic retro­version to compensate for the sagittal plane deformity. (c) Preoperative CT lumbar spine. He has a solid arthrodesis from L2 to L5. (d) Stage 1. AP and lateral intraoperative fluoroscopy. He was treated in a staged fashion with an L5-S1 ALIF to increase segmental lumbar lordosis and improve efficacy of arthrodesis across the lumbosacral junc­tion. (e) Stage 2. Lateral intraoperative fluoroscopy prior to the L2 extended PSO. Notice the kyphosis between the L1 and L3 pedicle screws. (f ) Stage 2. Lateral intraoperative
occurred from an angular correction) and significant sagit­tal plane correction. (a) Preoperative AP scoliosis X-rays. (b) Preoperative lateral scoliosis X-rays. (c) Postoperative AP scoliosis X-rays. (d) Postoperative lateral scoliosis X-rays
of deformity and health-related quality of life that can define specific goals for surgical reconstruction of the spine: SVA less than 4 cm, lumbar lordosis within 10º of the pelvic incidence, and pelvic tilt less than 20º.
• Ensure each patient has undergone careful preoperative optimization with a multidisci­plinary team prior to elective deformity surgery. Identify and treat reversible medical comor­bidities, consider physiatry for deconditioning and obesity, address nicotine cessation, and
fluoroscopy during the L2 extended PSO. The posterior elements were resected from the mid-pars of L1 to the top of the pedicle of L3, thus isolating the L2 pedicles bilat­erally. The L2 pedicles were subsequently removed. A wedge of the L2 vertebral body was resected with extension into the L1-2 disk space. The osteotomy was then closed. Notice the orientation between the L1 and L3 pedicles is now lordotic and that a wedge of bone has been resected from the L2 vertebral body. The Penfield No. 2 indicates bone-on-bone contact between the infe­rior endplate of L1 and the wedged L2 vertebral body. (g) Postoperative AP scoliosis X-rays. (h) Postoperative lateral scoliosis X-rays. SVA and lumbar lordosis are much improved
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J.N. Orina and S.H. Berven
Fig. 36.8 A 32-year-old female with adult idiopathic sco­liosis. She presents with limited L4 and L5 radicular pain and significant lumbosacral pain. (a) Preoperative AP sco­liosis X-rays. Her deformity has not progressed in the past 8 years. She is well aligned globally in the coronal plane.
optimize bone mineral density to minimize the risks of complications of care.
• Anterior surgery is a powerful tool to restore lumbar lordosis in patients with flat back deformity and significant pelvic incidence – lumbar lordosis mismatch. Anterior surgery is also an effective approach to correct a rigid fractional lumbosacral compensatory curve and increase arthrodesis rates in patients at risk for pseudarthrosis.
combination with an anterior approach in severe sagittal or coronal deformities. Type 5 and 6 osteotomies may lead to severe shorten­ing of the anterior and posterior spinal col­umns. Place an anterior cage to mitigate
(b) Preoperative lateral scoliosis X-rays. She is also well aligned globally in the sagittal plane. (c) Postoperative AP scoliosis X-rays. She was treated with a limited fusion from L4 to S1 with the goal of alleviating her radicular pain. (d) Postoperative lateral scoliosis X-rays
shortening and serve as a fulcrum for osteot­omy closure.
• Perform less extensive surgery in patients with stable spinal deformity, normal global bal­ance, and symptoms primarily consisting of radiculopathy. Less extensive surgery may include decompression alone or limited decompression and fusion.

Complications and Strategies for Avoidance

Surgical correction of adult spinal deformity is associated with a high risk of perioperative and postoperative complications [14, 57, 58]. A key
36 Principles of Deformity Correction
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principle in deformity correction is ensuring that both the surgeon and the patient have a thorough understanding of potential complications so an informed decision can be made by both parties regarding surgical intervention and strategy. Recognition of potential complications encour­ages the surgeon to anticipate adverse events and exercise prudence in selecting the techniques, tools, and implants that best achieve the goals of deformity correction while minimizing the risk of harm to the patient. In addition to the compli­cations specific to anterior surgery discussed pre­viously, perioperative complications may include neurological injury and causes of revision sur­gery such as pseudarthrosis and proximal junc­tional kyphosis (PJK).
Neurological injury can occur intraoperatively from direct trauma to the neural elements by instrumentation or surrounding bony and soft tis­sue structures during deformity correction. Deformity correction can also lead to neural injury from elongation of the spinal cord or a compromise of its vascular supply. The incidence of neurological injury depends on many factors including surgical approach, use of osteotomies, presence of kyphosis, and revision surgery [59]. Sansur et al. reviewed the Scoliosis Research Society Morbidity and Mortality Database and identified 4980 cases of patients with adult sco­liosis treated between 2004 and 2007. Ninety patients experienced a neurological complication (1.8%). Of these 90 patients, 71 (78.9%) patients experienced a nerve root injury, 11 (12.2%) patients had an incomplete spinal cord injury, 1 (1.1%) patient had a complete spinal cord injury, and 5 (5.6%) patients had cauda equina syndrome [60]. Lenke et al. reported a much higher rate of motor deficits in patients with complex three­column osteotomies, with measurable deficits in lower extremity motor scores in 22.2% of patients after surgery [61].
Intraoperative spinal cord and nerve root mon­itoring is appropriate for use in complex spinal realignment surgery. Somatosensory evoked potentials, motor evoked potentials, and electro­myography are valuable adjuncts for early detec­tion of neurological injury and rapid treatment of reversible causes. Motor evoked potentials pro-
vide direct monitoring of the corticospinal tracts and are the most sensitive neuromonitoring modality for detecting spinal cord injury. If any changes in neuromonitoring occur, the intraop­erative Stagnara wake-up test can be performed to directly examine the patient’s neurological function.
Pseudarthrosis and proximal junctional kyphosis are complications that are common sources of revision surgery. Kim et al. retrospec­tively reviewed 144 patients with adult spinal deformity undergoing long fusions to the sacrum and reported a pseudarthrosis rate of 24% [62]. Similarly, Dickson et al. retrospectively reviewed 171 patients undergoing lumbar pedicle subtrac­tion osteotomy and found a pseudarthrosis rate of
10.5% [63]. In the authors’ practice, strategies to avoid pseudarthrosis in adult spinal deformity include consideration and modification of patient factors (obesity, nicotine use, osteoporosis), meticulous preparation of the fusion surface, and use of recombinant human bone morphogenetic protein (rhBMP) for bone grafting. Studies have shown the use of rhBMP to be associated with significantly lower rates of pseudarthrosis com­pared to use of iliac crest bone graft [64]. Complications reported in the literature to be associated with rhBMP use include radiculopa­thy, seroma, and heterotopic ossification as well as possible tumorigenicity [64]. Thus, the sur­geon should carefully balance these risks and benefits when considering its use.
Proximal junctional kyphosis is defined as a postoperative proximal junctional Cobb angle greater than or equal to 10º between the inferior endplate of the uppermost instrumented vertebra and the superior endplate of the two vertebrae supra-adjacent and an increase in the proximal junctional Cobb angle greater than or equal to 10º from preoperatively. The reported incidence var­ies widely, from 10 to 40% [65, 66]. Risk factors include the proximal instrumented level selected, combined anterior-posterior surgeries, correction of SVA greater than 5 cm, and osteoporosis [67,
68]. Strategies to prevent PJK include avoiding
terminating a construct at a level that has 10 or greater degrees of proximal junctional kyphosis preoperatively. Additionally, the surgeon should
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J.N. Orina and S.H. Berven
avoid overcorrecting patients with significant sagittal plane deformity given the risk of PJK developing in patients with a change in SVA from preoperatively to postoperatively of greater than 5 cm. Future research may be aimed at designing techniques to reconstruct the posterior tension band at the proximal levels.

Conclusion

Spinal deformity has a significant and measur­able impact on health-related quality of life. The principles of deformity correction are based upon defining appropriate goals of care including pre­senting symptoms, radiographic alignment goals, patient safety, and patient and physician prefer­ence. There is a broad spectrum of surgical options for deformity correction, and the presence of variability in surgical approaches is a clear indication of the absence of a uniform consensus regarding an evidence-based approach to care. Informed choice regarding a surgical approach to deformity in the adolescent and the adult requires information on the natural history of deformity progression, symptoms, patient comor­bidities, and patient and surgeon preference. A dogmatic or monolithic approach to deformity correction is not appropriate, and the most appro­priate approach to care is the one that maximizes patient benefit while minimizing the risks and costs of care.

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