Spinal Osteotomy 2018

Spinal Osteotomy
นพ. ชัยยศ ทิรานนท์

รพ.สิรินธร สำนักการแพทย์ กรุงเทพมหานคร
Why Osteotomy?
• Goal of deformity surgery 
- deformity correction 
- rigid fusion 
- thorough neural decompression 
- archive sagittal and coronal balance 
• Some deformities are inflexible 

- previously fused  
- ankylosed 
- post traumatic / infection 
- neuromuscular disease
Mechanics
Posterior Column  Anterior Column 

Shortening Lengthening
Most commonly known osteotomies
• Smith – Petersen Osteotomy 
( SPO ) 
Ponte osteotomy , Chevron osteotomy
• Pedicle Subtraction Osteotomy 

( PSO )  
Eggshell osteotomy , Bone-disc-bone osteotomy
• Vertebral Column Resection 

( VCR )
Schwab Osteotomy Classification
Frank Schwab, Benjamin Blondel, Edward Chay, Jason Demakakos, Lawrence Lenke, Patrick Tropiano,
Christopher Ames, Justin S. Smith, Christopher I. Shaffrey, Steven Glassman, Jean-Pierre Farcy, Virginie
Lafage; The Comprehensive Anatomical Spinal Osteotomy Classification, Neurosurgery, Volume 74, Issue 1, 1
Grade I Osteotomy
• Partial / One
facet resection
• Smith-Petersen osteotomy
• Chevron osteotomy
• Extension osteotomy
Grade II Osteotomy
• Complete 
facet resection
• Ponte osteotomy
Smith-Petersen Osteotomy ( SPO )
This procedure was first described by Smith-Petersen in 1945 for ankylosing
spondylitis 
In 1984, Ponte described a very similar technique in Scheuermann’s kyphosis
• 7o – 10o correction per level
• 1o per 1mm of bone resected
• Often done in multiple levels 
• Anterior lengthening 
+ Posterior shortening
• Need mobile anterior column 
• Should be avoided in case with

calcified/rigid ALL,  
calcified vessels,  
immobile intervertebral disc 
- anterior vessels injury 
- limited correction
• Suitable for smooth – long kyphosis 
- flat back syndrome 
- Sheuermann’s kyphosis 
- Anderson’s lesion in AS
• Close down neural foramen :  
be careful in cases with foraminal stenosis
• Can be combined with interbody fusion to get more
correction angle
Grade III Osteotomy
• Pedicle  
+ Partial Body
Resection
Pedicle Subtraction Osteotomy ( PSO )
• 25o – 35o correction per level 
( max 60o )
• Suitable for  
- sharp angle deformity  
- fused multiple segments
• No anterior lengthening
• Asymmetrical resection for
coronal plane deformity
• Sagittal translation
• Iatrogenic thecal compression
• Infection
• Nerve root injury
• Bleeding
• Proximal junctional kyphosis
• Instrumentation
• Wide laminectomy 
remove all facets and TP
• Eggshell decancellation
• Blunt dissect lateral cortex 
beware segmental a.
• Remove pedicles
• Remove posterior cortex
• Remove lateral cortex 
temporary rod must be used
• Re-position table + 
compress the screws 
to close gap
Y-shaped vertebral column
decancellation ( VCD )
• More correction power than PSO 
• Less complications than VCR ??
Mehdian H, Arun R, Aresti NA. V-Y vertebral body osteotomy for the treatment of fixed sagittal plane
spinal deformity. The spine journal: official journal of the North American Spine Society. 2015;15(4):
Grade IV Osteotomy
• Pedicle  
+ Partial Body  
+ Disc  
Resection
Bone-Disc-Bone Osteotomy ( BDBO )
• The correction rates range
from 35° to 60° 
• May resect pedicle or not
• Might need anterior support

Bone-Disc-Bone Osteotomy ( BDBO )
Compared to PSO….
• Correction of the deformity at

its apex (CORA) 
= disc space
• Less aortic or inferior vena
cava obstruction secondary
to stretching
• Potential decrease in
pseudarthrosis rate due to
disc removal
• Better stability if pedicle
preserved ( 4 screws at
osteotomy site)
Grade V Osteotomy
• Complete
Vertebra and
Discs Resection
Grade VI Osteotomy
• Multiple Adjacent
Vertebrae and
Discs Resection
Vertebral Column Resection ( VCR )
• Commonly used for : 
- severe fixed trunk
translation 
- spinal column tumors  
- spondyloptosis  
- congenital kyphosis 
- hemivertebral excision
• Always need anterior

support
Vertebral Column Resection ( VCR )
• Highest complication rate 
- Neural injury : vertebral translation , dural bucking  
- Pulmonary : pneumothorax , PE , pneumonia 
- Vascular injury 
- Fixation failure , Pseudarthrosis
Planning
Bridwell KH.
Decision making regarding Smith-Petersen vs. pedicle subtraction osteotomy vs. vertebral
column resection for spinal deformity. Spine. 2006;31[19Suppl]:S171-8.)
Planning
Primary decisions to perform related to

1. Deformity location
2. Magnitude
3. Flexibility
4. Surgical goals
5. EXPERIENCE AND COMFORT
Planning
Planning
Patient Positioning
• 4-posts frame or 2 bolsters on foldable table 
Jackson table = the best , but expensive
• Allow space for correction / position changes
Patient Positioning
Cervical Osteotomy
• Mostly similar to thoracolumbar
• More risk of spinal cord injury
• Risk of vertebral artery injury
• Different parameters should be
concerned
• Commonly combined A-P approaches
Cervical Osteotomy Classification
A standardized nomenclature for cervical spine soft-tissue release and osteotomy for deformity correction:
clinical article.
Ames CP, Smith JS, Scheer JK, Shaffrey CI, Lafage V, Deviren V, Moal B, Protopsaltis T, Mummaneni PV, Mundis
GM Jr, Hostin R, Klineberg E, Burton DC, Hart R, Bess S, Schwab FJ, International Spine Study Group.
J Neurosurg Spine. 2013 Sep; 19(3):269-78.
Cervical Osteotomy Classification
A standardized nomenclature for cervical spine soft-tissue release and osteotomy for deformity correction:
clinical article.
Ames CP, Smith JS, Scheer JK, Shaffrey CI, Lafage V, Deviren V, Moal B, Protopsaltis T, Mummaneni PV, Mundis
GM Jr, Hostin R, Klineberg E, Burton DC, Hart R, Bess S, Schwab FJ, International Spine Study Group.
J Neurosurg Spine. 2013 Sep; 19(3):269-78.
Grade I : Partial facet joint resection
• Anterior : discectomy + partial uncinate resection
• Posterior : partial facet resection
• Limited correction power
• Need mobility of opposite column
• Commonly combined with other osteotomies 
Grade 2 : Complete facet joint resection 
• Need anterior column mobility

• Usually performed in multiple levels
• SPO , Ponte , Chevron osteotomy 
Grade 3 : Partial or Complete Corpectomy 
• Need posterior column mobility

• Fibula strut graft of iliac crest graft 
Grade 4 : Complete
Uncovertebral Joint Resection to
the Transverse Foramen
• anterior bony resection through the

lateral body and uncovertebral
joints into the transverse foramen 
• Helpful in completely ankylosed

anterior column 
Grade 5 : Opening Wedge
Osteotomy 
• complete resection of the

posterior elements, followed by
osteoclastic fracture and creation
of an anterior wedge in the
anterior column as in cases with
ankylosing spondylitis
Grade 6 : Closing Wedge
Osteotomy
• Pedicle subtraction osteotomy 
• Typically performed at C7-T1 

- below the entrance of the
vertebral arteries into the
transverse foramen 
- C8 root palsy has least morbidity
Grade 7 : Complete Vertebral
Column Resection
Take Home Messages
• Many patients have some degree of spinal
deformity
• Spinal osteotomies are becoming more common
• Extensive osteotomies should be preserved for
rigid deformities
• Bleeding control is very important
• It’s not that hard! Keep practicing!
THANK YOU

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Spinal Osteotomy

นพ. ชัยยศ ทิรานนท์

• Some deformities are inflexible

Posterior Column Anterior Column

• Pedicle Subtraction Osteotomy

• Vertebral Column Resection

• Should be avoided in case with

• More correction power than PSO

• Less complications than VCR ??

• May resect pedicle or not

• Might need anterior support

• Correction of the deformity at

• Always need anterior

Primary decisions to perform related to

• Need anterior column mobility

• Need posterior column mobility

• anterior bony resection through the

• Helpful in completely ankylosed

• complete resection of the

• Pedicle subtraction osteotomy

• Typically performed at C7-T1

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• Some deformities are inflexible 

Posterior Column  Anterior Column 

• Pedicle Subtraction Osteotomy 

• Vertebral Column Resection 

• More correction power than PSO 

• Pedicle subtraction osteotomy 

• Typically performed at C7-T1 