CHAPTER
82
Posterior Spinal Deformity
Correction Techniques
INTRODUCTION
Over the past decade, we have witnessed a dramatic advance in
the treatment strategies for a variety of complex spinal deformi-
ties affecting both children and adults. Many severe deformities
that were formerly treated in a staged circumferential anterior/
posterior manner are now corrected through a single-stage
posterior-only approach.5,12,13,16 Fundamental to optimal surgi-
cal care of a patient with spinal deformity is careful preopera-
tive assessment and planning. Reviewing the appropriate
imaging studies; evaluating the correction requirements in the
coronal, sagittal and axial planes; and determining whether or
not an osteotomy is required for spinal realignment are all
paramount issues to be considered preoperatively. In this chap-
ter, we will review modern techniques for posterior spinal
deformity correction. In addition to preoperative patient evalu-
ation and optimal intraoperative positioning, we will cover
implant considerations, osteotomies, and various posterior cor-
rection maneuvers that have become integral to our practice.
PREOPERATIVE ASSESSMENT
As with all conditions involving the spine, preoperative patient
evaluation begins with a thorough history, physical examina-
tion, and detailed neurologic assessment. In patients with spi-
nal deformity, it is important to get a sense of their inherent
curve flexibility, both clinically and radiographically. As part of
our clinical evaluation, we routinely compare patients defor-
mity while patients are standing versus lying prone on an exam-
ination table to determine whether their curves are flexible,
stiff, or stuck. It is occasionally surprising how flexible certain
very severe coronal and sagittal spinal deformities can be (Fig.
82.1). Patients with flexible deformities are often able to be
satisfactorily treated with basic ligament releases and correc-
tion by bringing the spine to an appropriately contoured rod
with multilevel segmental pedicle screw instrumentation.
Patients with stiff deformities, by contrast, frequently necessi-
tate additional intraoperative techniques to achieve the desired
correction. In most patients with stiff curves, apical facet-based
osteotomies (i.e., Pont osteotomies [POs] in the unfused
spine and SmithPetersen osteotomies [SPOs] in the posteri-
orly fused spine) are often sufficient to loosen the deformity
and thereby transform a stiff curve into a more flexible one. In
LWBK836_Ch82_p823-847.indd 823
Brian A. OShaughnessy
Lawrence G. Lenke
patients who are clinically deemed to be stuck (e.g., their curves
show no sign of demonstrable mobility with prone positioning
and truncal manipulation and confirmed radiographically),
more advanced osteotomies are often necessary for correction.
Provided the patient is medically able to sustain an extensive
operation, these severe immobile deformities are often best
treated with a three-column osteotomy such as a pedicle
subtraction osteotomy (PSO) or vertebral column resection
(VCR).4,17
Radiographically, patients initially obtain upright anteropos-
terior (AP) and lateral 14 36-inch radiographs to assess
regional and global spinal alignment.17,18 It is of utmost impor-
tance that patients do not use compensatory mechanisms dur-
ing their standing radiographs. Unilateral and/or bilateral
knee flexion is a common method by which a patient is able to
partially or completely reorient his or her head over the femo-
ral axis and compensate for an otherwise significant coronal
and/or sagittal imbalance. Hyperextension of the cervical spine
and retroversion of the pelvis are also common compensatory
mechanisms. A vertically oriented sacrum is a radiographic fea-
ture of long-standing sagittal compensation and must be noted.
Compensatory mechanisms will tend to underestimate the true
magnitude of the deformity and can result in undercorrection
if not recognized and accounted for in the surgical plan. Along
the same line, patients with long-standing sagittal imbalance
may rarely develop mild hip flexion contractures, especially if
they spend an inordinate amount of time sitting. These should
be recognized by the spinal surgeon and appropriately managed
in collaboration with a physiatrist and/or physical therapist.
Coronal curve flexibility is evaluated with side-bending,
supine, traction, and push prone images. Flexibility in the sagit-
tal plane is assessed with lateral hyperextension radiographs
over a bolster in younger patients with kyphosis. In the adult
population, plain lateral supine or prone radiographs are often
valuable determinants of sagittal curve mobility and overall
rebalancing. More commonly applicable in the pediatric popu-
lation, preoperative halo traction can be used both to evaluate
how stiff a deformity is and to gain small increments of correc-
tion in a safe, gradual fashion. In well-selected patients, we have
found preoperative halo traction to be extremely useful as both
a diagnostic and therapeutic tool in severe pediatric spinal
deformity (Fig. 82.2).19 It works particularly well in pediatric
and adult patients with a proximal thoracic or cervicothoracic
junctional kyphosis. Even patients who have been previously
823
8/26/11 5:42:53 PM
 824 Section VII Idiopathic Scoliosis

P.P.

35
26
10

10
110

52

5
5

X
cva

A
UPRIGHT SUPINE PUSHPRONE

Figure 82.1. Coronal flexibility radiographs. (A) A

588-year-old woman with a long-standing severe, left thora-
columbar scoliosis and severe coronal imbalance. She stood in
what appeared to be a rather fixed deformity with over 25 cm
of coronal imbalance from the midline, and chronic changes
of her right-sided lower ribs indented into the iliac wing.
However, on both supine and push prone positioning, her
coronal deformity corrected a substantial amount, showing
that it was rather flexible. (B) Similarly, in the sagittal plane,
B her forward sagittal imbalance realigned nicely on supine
UPRIGHT SUPINE positioning. (continued)

fused surgically and do not have instrumentation across their
prior fusion site can potentially benefit from halo traction. The
most common circumstance in which we use preoperative halo
traction is in a pediatric patient with a profound deformity that
is either very stiff or stuck and in whom we are considering a
VCR. In this setting, halo traction affords a more accurate
assessment of the curve rigidity than does plain imaging or
physical examination. Moreover, even in extremely rigid defor-
mities, halo traction often facilitates a gradual correction over a
sustained period without incurring any acute changes the spinal
cord might not tolerate. Patients are awake and are monitored
neurologically. In fact, although without scientific validation,
preoperative halo traction may, in certain cases, render correc-
tion with VCR safer. An additional benefit of preoperative halo

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 Chapter 82 Posterior Spinal Deformity Correction Techniques 825

D
Figure 82.1. (Continued) (C) She was treated with a long posterior reconstruction from T2 to the sacrum
and ilium with several thoracolumbar SmithPetersen osteotomies and a second stage anterior lumbar inter-
body fusion from L3 to the sacrum. Her 3-year postoperative radiographs show marked coronal and sagittal
rebalancing. (D) Pre- and postoperative clinical photos compliment the radiographic realignment.

traction in patients with severe deformities is that it affords
time during the hospitalization in which cardiopulmonary and
nutritional optimization can occur (Table 82.1).
In addition to plain radiographs, preoperative analysis of a
deformity will be augmented with computerized tomography
(CT) scan with or without myelography and/or magnetic reso-
nance imaging (MRI) in most cases. CT scan offers an in-depth
look at the bony architecture, thereby providing useful infor-
mation for osteotomy planning and screw placement. It also
provides a better evaluation of fusion (particularly in the
anterior column) and implant loosening than plain radiogra-
phy. In patients with a thick posterior fusion mass from prior
surgery, an axial CT can be useful for planning the size and
length of fusion mass screws. MRI is performed in any patient
with an unusual scoliosis or a severe kyphotic deformity in
which the spinal cord is displaced ventrally and draped over the
posterior vertebral bodies along the apex of the curve. In the
adult population, MRI is particularly valuable in assessing the
lumbar disc spaces and determining whether or not there is
evidence of central or lateral recess, or foraminal stenosis. The

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 826 Section VII Idiopathic Scoliosis

Figure 82.2. A 910-year-old boy who presented with a severe proximal thoracic kyphoscoliosis. He had a
left thoracic scoliosis of 138 and a kyphosis of 125. The apex of his coronal plane deformity was nearly
abutting the proximal ribcage. He was placed in prolonged halo-gravity traction and, with 25 lb of traction,
showed correction of the coronal plane to 100 and kyphosis to 111 with improved positioning of his
kyphoscoliotic apex off the ribcage.

integrity of caudal discs will often have an impact on distal
fusion levels, with markedly degenerated discs at the lum-
bosacral junction usually forcing the surgeon to extend the
fusion to the sacrum (Table 82.2).
Perhaps most important in the preoperative planning, par-
ticularly in evaluating patients who are radiographically can-
didates for three-column osteotomy (i.e., PSO or VCR), one
must determine their suitability for the procedure in terms of
physiologic and spinal cord reserve. Patients must have the
cardiopulmonary capability to withstand a physiologically tax-
ing procedure with the potential for substantial acute blood
loss. This is best assessed with multimodality preoperative test-
ing that includes a cardiac echocardiogram, carotid Dopplers,
and pulmonary function tests. There is also an element of
physician experience that goes into determining a patients
physiologic reserve. As important as physiologic prowess,
patients must have a healthy spinal cord if a three-column
osteotomy is planned in the thoracic spine or proximal lum-
bar spine at conus level. Even if the osteotomy is performed in
a technically flawless manner, the acute configuration change
associated with these procedures can be more than a sick
cord can tolerate. Patients with thoracic myelopathy and/or
prior anterior spinal surgery in which segmental vessels were
harvested appear to have heightened risk of neurologic com-
plications with thoracic VCR. Patients with chronic preopera-
tive neurologic impairment are often transiently worse after
surgery but do often improve with time, provided persistent
spinal cord and/or nerve root compression is not present.
Intraoperative cord hyperperfusion with iatrogenic systemic
hypertension (mean arterial pressure 80 to 90 mm Hg) dur-
ing surgery is of critical importance during the osteotomy to
limit neurologic sequelae.

Preoperative Radiographic
Advantages of Preoperative TABLE 82.2
Studies
TABLE 82.1
Halo Traction
Anteroposterior/lateral 14 36-inch radiographs (standing,
Provides information about curve stiffness supine, push prone, side-bending, films)
Often allows gradual correction by axial stretching of large CT scan: evaluation of bony architecture
deformities Magnetic resonance imaging: evaluation of neural elements
Patient is awake during the slow correction process and is (spinal cord, nerve roots) and disc integrity
neurologically monitored CT myelogram: evaluation of neural elements with indwelling
Time for preoperative respiratory therapy to improve pulmonary instrumentation
function
Preoperative nutritional supplementation CT, computed tomographic.

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 Chapter 82 Posterior Spinal Deformity Correction Techniques 827

INTRAOPERATIVE POSITIONING
Prone positioning for posterior spinal reconstruction involves
appropriately padding all bony prominences and ensuring that
the spine is also aligned with the hips extended. Optimal posi-
tioning of the head and neck is of critical importance when
involving the cervical spine and occiput in a fusion since the abil-
ity of the patient to accommodate is vastly diminished postopera-
tively. An open Jackson frame with adjustable pads is used in
most patients; however, in very small patients, a closed frame with
chest rolls is more effective. The proximal pads must be clearly
free of the axilla to avoid any undue pressure on the brachial
plexus. Patients are placed in either GardnerWells tongs or a
halo with gentle (10 to 15 lb) axial traction to keep the face and
eyes free of pressure during surgery. Patients who were placed in
halo-gravity traction preoperatively are positioned in their halo
with a reduced amount of traction weight. Counter-traction (20
to 30 lb) using a femoral traction pin is typically performed in
neuromuscular deformities with a significant amount of pelvic
obliquity (Fig. 82.3).7,20 Because spinal distraction forces are

B
Figure 82.3. (A) A 142-year-old boy with arthrogryposis and a severe 153 right thoracolumbar scoliosis.
His supine correction was to 99 and push prone to 120. (B) To optimize his spinopelvic realignment, he
underwent intraoperative halo-femoral traction with a unilateral left-sided femoral traction pin placed. He
had 15 lb of traction placed on his halo and 20 lb on his femur. (continued)

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 828 Section VII Idiopathic Scoliosis
C
Figure 82.3. (Continued) (C) He then underwent a posterior spinal fusion from T2 to the sacrum and
ilium with intraoperative traction and apical SmithPetersen osteotomies. His 2-year radiographs demon-
strate a correction of 46 of residual curvature with a nearly level pelvis in the upright position.
introduced with femoral counter-traction, this technique should
be strictly avoided in patients with an angular kyphosis and/or
those undergoing a VCR where any undue distracting tension on
the spinal cord at the time of surgery may be harmful.
Often, with general anesthesia, use of a muscle relaxant, and
proper prone positioning, reasonably flexible deformities are sig-
nificantly improved. Intraoperative radiography is performed in
all cases toward the end of subperiosteal spinal exposure with the
dual purpose of level localization and reevaluation of spinal align-
ment. These radiographs are often helpful adjuncts during place-
ment of segmental instrumentation and, in rare circumstances,
can alter the surgical plan such that a less challenging osteotomy
plan is utilized because of better spinal alignment than seen on
preoperative supine radiographs. In fact, a recent study in adult
spinal deformity patients found an additional mean 17 more
lumbar lordosis intraoperatively during prone positioning as
compared with the upright preoperative lateral radiograph.6
IMPLANT CONSIDERATIONS
Integral to posterior spinal deformity correction is obtaining
solid points of vertebral fixation to both facilitate correction
and allow the maintenance of a stable spinal configuration
while the process of bony fusion takes place. In most cases, we
prefer segmental pedicle screw instrumentation to other forms
of spinal implant such as hooks or sublaminar wires. Pedicle
screws have the advantage over other fixation choices because
of increased insertional torque due to fixation of the spine in
all three columns. Three-column control not only offers a more
robust grip of the spine but also allows true axial derotation in
cases of scoliosis. The one exception to this is the use of fusion
mass hooks to close spinal osteotomies.22 We routinely place
well-seated hooks above (downgoing) and below (upgoing)
LWBK836_Ch82_p823-847.indd 828
three-column osteotomies to slowly compress the osteotomy
limbs closed posteriorly with a central rod mechanism.
Thoracic pedicle screws, which have been studied extensively
over the past decade, are the ideal method of bony fixation in the
thoracic spine.911,14 In our hands, screws are placed by using an
open freehand technique with starting points determined by pos-
terior element topography. Even in patients with prior surgery
and distorted surface anatomy, critical landmarks for screw place-
ment including the pars interarticularis, transverse process, and
superior articular facet are often still present. A curved, blunt tip
gearshift is used to develop a pedicle tract prior to screw place-
ment.10 This strategy has been proven to be safe and effective
even in cases of very severe deformity11 as well as in a revision set-
ting.9 Although we perform screw placement without image
guidance, each surgeon should utilize a safe technique that works
effectively and efficiently. Ancillary techniques to facilitate tho-
racic pedicle screw placement include undertapping over a
K-wire and fluoroscopic or stereotactic CT guidance. Stereotaxy
with CT scan can be useful in cases with a large posterior fusion
mass that has obliterated all visual cues as regards to an appropri-
ate starting point. Particularly in cases of severe deformity, pre-
liminary apical facet osteotomies (POs or SPOs) performed for
correction purposes can also be quite helpful during apical screw
placement as the spinal canal and medial pedicle border are
then accessible. All pedicle screws are checked with intraopera-
tive radiographs. Intraoperative CT scans, which have recently
become available, are also useful in confirming appropriate screw
placement. Some of the scatter artifact from stainless steel (SS)
implants can render the intraoperative CT scan difficult to inter-
pret; however, a high-resolution scan can often allow the surgeon
to pick up any clinically significant violations. Electromyographic
stimulation of screws below T5 is also performed.
Types of pedicle screws that we commonly use are monaxial,
multiaxial, and multiaxial reduction screws (MARS). Monaxial
8/26/11 5:42:58 PM

screws, placed using a straightforward trajectory, are low profile
and used preferentially in locations where implant prominence
is a real concern, such as along the periapical convexity in ado-
lescent idiopathic scoliosis and other scoliotic deformities.
MARS are placed strategically in the following locations: (1)
apical concavity of a scoliosis, (2) proximal and/or distal levels
of a severe kyphosis or kyphoscoliosis, (3) the concavity of any
deformity in the lumbar spine, and (4) above and below a PSO
or VCR. Apical concave MARS in scoliosis allow the spine to
translate posteriorly and derotate in the axial plane. In the set-
ting of a PSO or VCR, MARS can be used above and below the
osteotomy to counteract any pathologic segmental translation.
In general, while MARS tend to introduce kyphosis as they have
the potential to translate the spine posteriorly as the rod is
being reduced, these implants can be used effectively for a vari-
ety of circumstances in which versatility is valued.
All patients with a de novo fusion down to the sacrum are
instrumented with bilateral tricortical sacral pedicle screws
and a second form of caudal fixation, either alar screws or,
more commonly, iliac screws.21 Sacral alar screws offer three
primary advantages over iliac screw fixation: (1) decreased
prominence, (2) implants confined to fused segments thereby
minimizing the risk of screw pullout or fracture with time, and
(3) does not cross the mobile sacroiliac joints. Alar screws are a
consideration in the setting of a shorter fusion to the sacrum in
a young, thin patient (e.g., high-grade spondylolisthesis). In
the overwhelming majority of long adult posterior spinal recon-
structions with fusion to the sacrum, iliac screws are utilized
because of the powerful resistance to cantilever forces afforded
by these implants. In addition to iliac fixation, structural inter-
body cages or grafts are routinely placed at unfused caudal seg-
ments through a transforaminal access portal. In addition to
providing a solid foundation for a long fusion to the sacrum,
caudal segment interbodies are able to increase foraminal
height and thus relieve lumbosacral nerve root compression in
the lateral recess and foramen due to hypertrophied ligamen-
tum flavum, overgrown facets, and degenerated discs.
Beyond gaining segmental control of the spine, posterior
deformity surgery requires strategic selection of the rod, both
in terms of caliber and metal. The large majority of our defor-
mity reconstructions are performed with SS implants. SS is an
ideal rod for deformity because of its strength, in situ contour-
ing ability, and lack of the notch sensitivity of titanium (Ti)
when bent. Notching of Ti rods predisposes to rod fracture, a
clearly undesirable event that may result in loss of correction
and predisposed to pseudarthrosis. The primary drawback to
the use of SS implants is the impressive streak artifact that ren-
ders interpretation of postoperative CT scans challenging and
MRIs nearly impossible. In patients fused down to the sacrum
for deformity without any spinal cord issues, SS is the implant
of choice. Reconstructions for tumor, however, are better man-
aged with Ti constructs which has the advantage of facilitating
spinal cord and spinal column visualization on subsequent
postoperative MRIs.
In recent years, we have started selectively using cobalt
chrome (CoCr) rods with Ti screws. CoCr rods, currently avail-
able with a diameter of 5.5 mm, lack the notch sensitivity of Ti,
are stiffer and stronger than similarly sized SS rods, and possess
MRI compatibility closer to Ti than SS constructs. In patients
with spinal deformity who are fused short of the sacrum, CoCr
instrumentation is ideal because it allows visualization of the
neural elements and caudal discs after surgery, which can be
LWBK836_Ch82_p823-847.indd 829
Chapter 82 Posterior Spinal Deformity Correction Techniques 829
followed and reevaluated should the patients subsequently
develop distal degeneration.
The ideal rod diameter utilized is determined on the basis
of the patient size and the magnitude of the deformity and cor-
rection technique. Patients with adolescent idiopathic scoliosis
are often treated with either 5.5-mm SS or 5.5-mm CoCr
implants. Thin adult patients without severe deformities are
also frequently managed with 5.5-mm diameter rods. By con-
trast, large adult patients are more commonly instrumented
with a 6.35-mm SS system. Similarly, large adolescent patients
in their late teen years with adult spine are sometimes man-
aged with a 6.35-mm SS rod. Not uncommonly, we will use a
6.35-mm SS rod on the correcting side and a 5.5-mm SS rod on
the contralateral holding side (Fig. 82.4). Also at our disposal,
and commonly used in long adult deformity reconstructions,
are 6.35- to 5.5-mm transition rods. We will often use a 6.35-/
5.5-mm transition rod with the 6.35-mm portion at the lum-
bosacral junction and lumbar spine, and the transition to
5.5-mm introduced just above the thoracolumbar junction. Of
course, in juvenile and infantile pediatric patients with a smaller
body habitus, 4.5-mm and 3.5-mm SS systems are frequently
used (Table 82.3).
OSTEOTOMIES
Osteotomies are the primary tool in the surgical armamentar-
ium by which the spinal surgeon can introduce mobility into the
spinal column and effectively restore spinal balance in cases of
severe deformity (Table 82.4). The simplest form of posterior
release is resection of the ligaments that comprise the posterior
tension band, the so-called soft tissue release. Although, strictly
speaking it is not an osteotomy, a properly performed soft tissue
release can introduce a significant amount of flexibility into the
spinal column in appropriate patients. The most commonly
performed true osteotomies in reconstructive posterior spinal
deformity surgery are facet-based osteotomies (POs and SPOs)
and three-column osteotomies (PSO and VCR). The choice of
osteotomy is dependent on a variety of factors including the
goals of the procedure, correction requirements, native bone
quality of the patient, subsequent screw purchase, and the anat-
omy of the deformity. Each of the posterior osteotomy tech-
niques has specific advantages as well as inherent drawbacks and
limitations. They can be used individually or together in combi-
nation to achieve the desired correction17 (Fig. 82.5).
Soft Tissue Release
As stated, a soft tissue ligamentous release is not truly an osteot-
omy; however, for many posterior deformity cases, it is adequate
to achieve an excellent correction. For most primary adoles-
cent or adult idiopathic scoliosis curves in the 50 to 70 range
with flexibility, soft tissue release is all that is needed, particu-
larly when coupled with bilateral segmental pedicle screw
instrumentation. Soft tissue release involves resection of the
interspinous ligament, ligamentum flavum, and facet capsules
bilaterally. In addition to removing the facet capsules, partial
inferior facetectomies are performed at all levels being instru-
mented and fused with the exception of the distal instrumented
vertebrae. Resection of these structures comprising the poste-
rior tension band often results in substantial mobility to most
curves, including the ability to increase kyphosis at the lordotic
apex of idiopathic thoracic deformities.
8/26/11 5:42:59 PM
 830 Section VII Idiopathic Scoliosis

Figure 82.4. (A) A 147-year-old girl with a 70 Lenke 1AN AIS curve. (B) She was treated with a poste-
rior spinal fusion from T3 to L1 with segmental pedicle screws, and an apical derotation maneuver. She had
a 6.35-mm stainless steel correcting rod placed on the left side and a 5.5-mm holding rod on the right side.
Her postoperative radiographs show normalized coronal and sagittal alignment and apical derotation seen by
the screw position. (continued)

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 Chapter 82 Posterior Spinal Deformity Correction Techniques 831

C
Figure 82.4. (Continued) (C) Her pre- and postoperative clinical photos show nice clinical alignment and
balance.

Facet-Based Osteotomies more beneficial from a bonescrew interface standpoint, pro-

POs and SPOs are facet-based osteotomies performed in the
unfused and posteriorly fused spine, respectively. For the pur-
pose of this chapter, we will refer to these osteotomies collec-
tively as SPOs. In theory, the SPO offers approximately 10 of
sagittal correction per level; however, 5 to 7 per level is more
commonly achieved.4,17 It can be performed at any level in the
thoracolumbar spine and, because it involves opening of the
anterior column during kyphosis correction, a requirement is
that it is performed at segments not anteriorly ankylosed
(unless the anterior fusion can be cracked open as in ankylo-
sing spondylitis). Scheuermanns kyphosis is the prototype
deformity where periapical SPOs allow posterior-only treatment
of even stiff curves (Fig. 82.6). Anterior column ankylosis is
usually clearly visualized on preoperative radiographs or a CT
scan. Primary stiff coronal plane deformities, such as severe
adult thoracic scoliosis, can often be treated with multilevel
SPOs and segmental pedicle screws. Correction from SPOs can
involve multiple rounds of compression and, as a result, strong
segmental fixation is paramount. In older, osteoporotic patients
with weak anchor points, a three-column osteotomy may be
vided they can tolerate the procedure physiologically.
As discussed earlier, a lateral radiograph with the patient
positioned supine offers a great deal of information about sagit-
tal curve flexibility and is valuable when considering SPOs as the
primary correction osteotomies. The taller the disc, the more
effective a SPO can be. If the disc is severely degenerated and
collapsed, placement of a structural interbody graft anteriorly in
the disc space can restore disc space height and allow greater
correction from posterior closure of a SPO. In using this tech-
nique, one caveat is that large interbody spacers not placed
anterior enough in the disc space can block posterior closure of
a SPO and result in limited segmental sagittal plane correction.
One important consideration is the risk of pitching a patient
with kyphoscoliosis off to the concavity of the deformity with
multilevel SPOs. In a scoliotic deformity, the anterior column is
close to the convexity and the posterior column toward the
concavity. Correction via SPOs results in posterior column
(concave) shortening and anterior column (convex) lengthen-
ing. As a result, kyphosis correction with SPOs can be accompa-
nied by coronal plane decompensation toward the concavity.
This can be averted by performing asymmetric SPOs in which

TABLE 82.3 Characteristics of Metals for Rod Selection

Titanium Cobalt Chromium Stainless Steel

Least artifact on CT/MRI
Best for infection
Notch sensitive
D: 5.5 mm, 6.35 mm
Not ideal for deformity
Limited artifact on CT/MRI
Good for infection*
Not notch sensitive
D: 5.5 mm, 4.75 mm
Excellent for deformity
Worst artifact on CT/MRI
Worst for infection
Not notch sensitive
D: 5.5 mm, 6.35 mm
Excellent for deformity

CT, computed tomography; D, commonly available rod diameter; MRI, magnetic resonance imaging.
*
Further basic science and clinical data needed to confirm the infection profile for cobalt chromium
spinal instrumentation.

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 832 Section VII Idiopathic Scoliosis

Osteotomies in Spinal Smooth Deformity Focal Deformity

TABLE 82.4
Deformity Surgery
Soft tissue/ligament release Thoracic Lumbar Thoracic Lumbar
Pont osteotomy (facet-based osteotomy in the unfused spine)
SmithPetersen osteotomy (facet-based osteotomy in the fused
Anterior Column Fused?
spine)
Pedicle subtraction osteotomy
Vertebral column resection
Yes No Yes No

VCR POs/SPOs PSO POs/SPOs VCR PSO

the convex portions of the osteotomies are larger and both sides
are compressed equally.4 Last, multilevel SPOs are required in
attempting to correct thoracic lordosis deformities from the
posterior route as the posterior ligamentous structures are
severely shortened and thickened. Thus, release of these poste-
rior structures will be essential for the posterior lengthening
required to produce kyphosis (Fig. 82.7).
Pedicle Subtraction Osteotomy
PSO, a far more powerful technique than SPO, can reliably
achieve between 30 and 40 of focal sagittal correction at a
single segment.13,8,17 This technique involves removal of the
pedicles, facet joints above and below, and resection of a trian-
gular wedge of bone from the vertebral body. PSO results in a
sagittal plane correction, which is determined by the extent of
the wedge resection. Unlike a SPO, the rigidity of the anterior
Figure 82.5. Algorithm in osteotomy planning for severe deformi-
ties. This algorithm must be interpreted as a general guide. Every
patient and spinal deformity is different. The appropriate surgical
treatment must be determined on a case-by-case basis. For example,
in a patient with a smooth lumbar kyphosis and profound global sagit-
tal imbalance, a lumbar pedicle subtraction osteotomy (PSO) is often
warranted. POs: Pont osteotomies; SPOs: SmithPetersen osteoto-
mies; VCR: vertebral column resection.
column is irrelevant in performing a PSO and, if anything, is
helpful in terms of added stability during osteotomy closure.
An asymmetric PSO can also be performed to achieve a com-
bined coronal and sagittal correction. A super foramen is cre-
ated that houses the root at the level of the PSO and the root
at the level above the PSO. While thoracic PSOs have been
described,14 PSO is a technique most useful in the lumbar

Figure 82.6. A 15-year-old girl with a 94 Scheuermanns kyphosis with correction over a bolster with
hyperextension corrected to 60. She underwent a posterior-only spinal reconstruction from T4 to L2 with
apical SmithPetersen osteotomies, demonstrating correction to 37 at 3 years postoperative without any
junctional problems and overall good sagittal balance.

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 Chapter 82 Posterior Spinal Deformity Correction Techniques 833

x
9+4 9+4
2 2

50

10 56
11
Figure 82.7. Severe thoracic lordoscoliosis. (A) A 9
4-year-old girl with a history of total spine radiation due to
neuroblastoma as an infant. She had a progressive lor-
doscoliosis with 50 of coronal plane deformity and 56
of thoracic lordosis. Her pulmonary function values were
13% FVC and 14% FEV1 preoperative. She was actually
referred to our center for consideration of a lung trans-
plant; however, her severely limited thoracic chest volume
precluded consideration because of her severe spinal
deformity. (B) She underwent a posterior reconstruction
from T2 to L1 with apical SmithPetersen osteotomies and
posterior translation using multilevel bilateral reduction x
screws. Her postoperative radiographs show correction of sva
the coronal plane to 10 and more than 75 of thoracic
kyphosis reduction to 21 postoperatively. (continued) A

9+4 9+4 x 1-29-07

1-29-07
2 x
2 2
2

50
10

+21

10
10 56

11
11

x
sva
x
sva
B

LWBK836_Ch82_p823-847.indd 833 8/26/11 5:43:01 PM

 834 Section VII Idiopathic Scoliosis
C
Preoperative
Figure 82.7. (Continued) (C) Pre- and postoperative computed tomographic scans show a markedly
improved space for her heart and lungs and improvement in her FVC and FEV1.
spine. When PSOs are performed at the thoracolumbar junc-
tion (T10 through L1), we will often remove the superior disc
and close the inferior end plate of the body above onto the
osteotomy for added correction (Fig. 82.8). This strategy also
removes one additional disc around the PSO that could poten-
tially lead to a pseudarthrosis.
Vertebral Column Resection
VCR, an extension of the pedicle subtraction technique, involves
resection of the posterior elements, entire vertebral body, and
the discs above and below. Although originally described as an
anterior/posterior procedure, we now perform this osteotomy
through a posterior-only bilateral costotransversectomy
approach.13,16 Its correction potential is most significant in
severe angular deformities.16 PSO and VCR are not differenti-
ated by the amount of bone resection so much as they are dif-
ferent in terms of correction mechanics. Unlike a PSO, in which
there is a fixed osteotomy closure angle determined by the
parameters of the wedge resection, VCR has no such closure
angle. VCR is a spinal dissociation osteotomy in which the arc of
correction is anterior to the spinal canal. Because of the tremen-
dous instability created during the performance of the osteot-
omy, the value in the early application of temporary rods cannot
be overstated.
Correction from a VCR is typically larger than that afforded
by a PSO and appears to be dependent on a number of factors
including the focality of the deformity and height of the struc-
tural intracorporeal cage utilized (Fig. 82.9). VCR is a tech-
nique best suited for the thoracic spine where PSO is less effec-
tive due to the short, triangular shape of the thoracic vertebral
bodies.15,16 Moreover, since thoracic nerve roots can be sacri-
ficed with impunity, VCR is readily accomplished and working
space is rarely a problem. We utilize this technique from T2 to
L1, inclusive. Below L1, because of the critical need for nerve
root preservation, we typically find PSO to be more practical,
except in unusual circumstances.
LWBK836_Ch82_p823-847.indd 834
Postoperative
CORRECTION TECHNIQUES
Scoliosis
Posterior spinal deformity correction techniques for scoliosis
are idiosyncratic and therefore highly surgeon dependent. In
recent years, posterior approaches for idiopathic scoliosis, even
in anteriorly accessible adolescent idiopathic thoracolumbar
(Lenke type 5) curves, have predominated. Three-column con-
trol afforded by segmental pedicle screw instrumentation allows
the surgeon to manipulate the spine and introduce forces in a
variety of manners and sequences to produce optimal correc-
tion and spinal realignment. Moreover, particularly important
in the lumbar spine and thoracolumbar junction, the potential
kyphosing effect of anterior correction is avoided.
One major advantage of pedicle screw fixation is the wide
variety of correction techniques and maneuvers available.
Besides the traditional forces of posterior compression (to close
open discs and lordose) and distraction (to open close discs
and kyphose), pedicle screws allow any type of anterior, poste-
rior, medial, and/or lateral translational forces to be applied to
the screw itself, or to the rod/screw construct once attached. In
addition, one unique advantage to pedicle screw fixation is the
ability to perform segmental and/or en bloc derotation at the
apex of the scoliosis. This has revolutionized the treatment of
adolescent idiopathic scoliosis (AIS) in that the rib prominence
is consistently improved during the reconstruction to obviate
the need for a thoracoplasty procedure in most cases.
The sequence of correction maneuvers depends on many
factors, including the size of the coronal plane deformity, sag-
ittal plane alignment, and planned instrumentation to be uti-
lized. We consistently use either SS or CoCr as our choice for
the rods utilized to correct spinal deformity. In our SS con-
structs used for thoracic AIS, typically we will consider a
5.5-mm diameter rod, or a hybrid construct consisting of a
6.35-mm concave correcting rod and a 5.5-mm convex holding
rod. The increased strength of the 6.35 mm rod allows for cor-
recting the apical lordosis (typically with multiaxial reduction
8/26/11 5:43:02 PM

Figure 82.8. (A) A 541-year-old woman with a long-standing
untreated thoracolumbar kyphoscoliosis measuring 110 in the sagittal
plane and 85 in the coronal plane, which side bends to only 77. She has
concomitant thoracolumbar kyphosis and positive sagittal imbalance as
well. (B) Her hyperextension lateral radiograph shows correction of her
110 thoracolumbar kyphosis to only 80. She has a very stiff
deformity. (continued)
screws-MARS) by pulling the spine posteriorly to the stiffer
kyphotically bent rod. The also affords a means of apical dero-
tation by the posterior and simultaneous medial translation
that occurs by this maneuver. The 6.35-mm concave rod is
captured above (set plugs loose) and below (set plugs tight)
after adjusting to the optimal sagittal plane alignment of the
precontoured rod. Then the intermediate screws are captured
from the ends to the apex, along with the apical MARS uti-
lized in a similar fashion as described earlier. Once the cor-
recting rod is locked, a coronal in situ bending can be per-
formed to optimize scoliosis correction, and then appropriate
compression and distraction forces may be applied to opti-
mize the tilt required of the upper instrumented vertebra
(UIV) and lower instrumented vertebra (LIV) to maximize
optimal balance of the spine above and below. Then the
LWBK836_Ch82_p823-847.indd 835
Chapter 82 Posterior Spinal Deformity Correction Techniques 835
B
5.5-mm holding rod is placed in situ with compression forces
applied across the convex apex and also appropriate forces to
the UIV/LIV to further optimize tilt. Postcorrection, long cas-
sette intraoperative radiographs are then obtained to evaluate
the spine for appropriate correction and balance and minor
adjustments made as needed.
Thus, most primary cases of adolescent idiopathic scoliosis
are well treated with multilevel soft tissue releases, pedicle
screws, and various correction maneuvers as described. The use
of MARS along the apex of the concavity results in controlled
posterior translation and derotation (Fig. 82.10). Drawing the
spine posteriorly to the rod by using MARS in the thoracic
spine is particularly advantageous in idiopathic scoliosis in an
attempt to normalize the sagittal plane, which is usually in lor-
dosis at the apex.
8/26/11 5:43:03 PM
 836 Section VII Idiopathic Scoliosis

D
Figure 82.8. (Continued)(C) She underwent a posterior reconstruction from T3 to the sacrum and ilium
with a transforaminal lumbar interbody fusion at L5-S1, and an L1 extended pedicle subtraction osteotomy
(including the T12/L1 disc). Her pedicle subtraction osteotomy was closed with a central hookrod mecha-
nism that was kept for additional fixation. At 2 years postoperative, she has very nice realignment of her coro-
nal and sagittal plane deformity with good overall balance. (D) Pre- and postoperative clinical photos
demonstrate the triplanar correction afforded by this three-column osteotomy procedure.

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 Chapter 82 Posterior Spinal Deformity Correction Techniques 837

Figure 82.9. Severe scoliosis. (A) A 126-year-old girl who presented with a severe 159 adolescent idio-
pathic scoliosis. On side bend, her curve corrected to only 135. (B) She underwent preoperative halo-gravity
traction and a single-level posterior vertebral column resection with instrumentation and fusion from T2 to
L4. At 2 years postoperative, her correction is to 32 in the coronal plane. (C) Pre- and postoperative clinical
photos demonstrate the marked correction of her severe truncal deformity.

LWBK836_Ch82_p823-847.indd 837 8/26/11 5:43:05 PM

 838 Section VII Idiopathic Scoliosis

B
Figure 82.10. (A) A 131-year-old girl with a 91 Lenke 2BN adolescent idiopathic double thoracic
scoliosis. Her side bending correction was 26 for the proximal thoracic curve and 47 for the main thoracic
curve demonstrating 48% correction. (B) She underwent a posterior spinal fusion from T2 to L2 with apical
SmithPetersen osteotomies and multiple concave periapical multiaxial reduction screws. Her main thoracic
curve improved to 12 of residual deformity demonstrating 88% correction. She was well balanced
radiographically. (continued)

LWBK836_Ch82_p823-847.indd 838 8/26/11 5:43:07 PM


C
Figure 82.10. (Continued) (C) Her pre- and postoperative clinical photos demonstrate the marked
truncal realignment in the coronal and axial perspectives.
In children with scoliosis, use of the vertebral column
manipulator (VCM) device (Medtronic Spinal and Biologics,
Memphis, Tennessee) can result in powerful derotation of the
spine along the apex of the curve and subsequent remodeling
of the chest wall. The VCM works by linking multiple screws
bilaterally, which enables a significant derotation force to be
applied to the spine and minimizes the stress on any one bone
screw interface. One noteworthy drawback of the VCM is the
proclivity to produce lordosis along with axial derotation; for
this reason, preexisting thoracic lordosis is a relative contrain-
dication. The VCM is especially useful in the lumbar spine to
provide optimal correction when attempting to stop at the L3
level (Fig. 82.11).
In patients with larger and stiffer curves, periapical SPOs
are required to introduce flexibility into the deformity. Apical
SPOs are also helpful during concave screw placement, which
can be particularly challenging due to the often tiny, sclerotic
pedicles in this region and the proximity of the spinal cord
(Fig. 82.12). In extremely stiff and profound deformities, VCR
is the procedure of choice. Through a posterior-only approach,
VCR allows tremendous correction potential and nice reduc-
tion of the rib hump. In scoliosis, VCR correction is introduced
by compression of the osteotomy along the convexity of the
curve and in situ rod contouring. In most cases, SPOs above
and below the VCR are useful to achieve additional correction
if needed.
LWBK836_Ch82_p823-847.indd 839
Chapter 82 Posterior Spinal Deformity Correction Techniques 839
Kyphosis
As described, the most fundamental posterior approach to
kyphotic deformity is SPOs and segmental pedicle screw instru-
mentation (see Fig. 82.10). SPOs are performed in the periapi-
cal region over multiple segments, and deformity correction is
achieved by a combination of cantilever forces and segmental
compression. MARS are used at the distal end of the construct
to capture the rods as they are bilaterally cantilevered across the
apex of the kyphosis. A rocker-blocker is used to sequentially
cantilever the rod into each screw while continuing to tighten
the reduction set screws on the distal levels. Rounds of compres-
sion are then applied at each level. Compression across the
osteotomies is preferentially performed pushing caudal on the
screws as the inferior pedicle appears to be stronger under com-
pressive forces than the superior pedicle. Compression forces
are introduced slowly and correction is performed gradually.
The principle of back-and-forth is initiated in which multiple
rounds of compression to achieve small incremental amounts of
correction each time. This strategy allows the interplay between
stress relaxation of the soft tissues with creeping correction of
the spinal deformity.
As described earlier, severe fixed deformities may be treated
with a three-column osteotomy such as a PSO or a VCR. Angular
deformities involving the thoracic spine are often best treated
with a VCR. Also, in the past 6 years, both primary (Fig. 82.13)
8/26/11 5:43:08 PM
 840 Section VII Idiopathic Scoliosis

B
Figure 82.11. (A) A 158-year-old girl with a Lenke 3C adolescent idiopathic double major scoliosis.
Preoperatively, L3 had 21 of tilt, and the center sacral vertical line just barely touched the lateral edge of the
inferior portion of the body. The lumbar curve was reasonably flexibly. (B) She underwent a posterior spinal
fusion from T4 to L3 with an apical derotation maneuver by using the vertebral column manipulator device
in the lumbar spine. At 2 years postoperative, L3 is well centered with a 0 tilt angle with excellent
radiographic alignment and balance.

and revision (Fig. 82.14) severe thoracic kyphoscoliotic defor-
mities have been managed with VCR procedures. By contrast,
stiff or fixed lumbar imbalances are frequently better managed
with a PSO. Of course, the anatomy of each deformity must be
considered along with several other factors to develop the ideal
operative plan. Correction of kyphosis with a three-column
osteotomy is typically by gentle compressive forces. If more
than gentle force is required for osteotomy closure, one should
reevaluate the carpentry at the osteotomy site and determine
whether additional resection is required.
During closure of a three-column osteotomy, the distal limb
of osteotomy may translate ventrally relative to the proximal
limb. This occurs because the hips are extended forcing the
lumbosacral spine into lordosis. To counteract this tendency,

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 Chapter 82 Posterior Spinal Deformity Correction Techniques 841

B
Figure 82.12. (A) A 4710-year-old woman with an untreated adult thoracic idiopathic scoliosis. She has
a 93 thoracic deformity, 65 lumbar deformity. The thoracic deformity was quite stiff, with only 8%
flexibility bending to 86. (B) She underwent a posterior spinal reconstruction from T3 to L4 with multilevel
apical SmithPetersen osteotomies and translational correction with multiaxial reduction screws. At 3 years
postoperative, she has acceptable realignment of her coronal plane deformity and good overall coronal and
sagittal balance. (continued)

LWBK836_Ch82_p823-847.indd 841 8/26/11 5:43:10 PM

 842 Section VII Idiopathic Scoliosis

Figure 82.12. (Continued) (C) Pre- and postoperative clinical photos demonstrate the marked correction
of her truncal deformity, including the improved rib prominence, which was obtained with spinal correction
alone, as a thoracoplasty was not performed.

A
Figure 82.13. Adult idiopathic kyphoscoliosis. (A) A 587-year-old woman with a long-standing untreated
98 right lower thoracic scoliosis side bending to only 76. She has an associative 109 of thoracic kyphosis.
She was also osteoporotic. (continued)

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 Chapter 82 Posterior Spinal Deformity Correction Techniques 843

Figure 82.13. (Continued) (B) On lateral view, her 109

of kyphosis corrected to only 68 over a bolster in hyperex-
tension. (C) Because of her large stiff triplanar deformity and
concomitant osteoporosis, she underwent a posterior recon-
struction from T2 to L4 with an apical posterior vertebrec-
tomy at T10. She had an anterior cage placed through this
approach for an anterior fusion from T9 to T11 as well. At 2
years postoperative, she has marked realignment of both cor-
onal and sagittal planes and good overall balance. (continued) B

LWBK836_Ch82_p823-847.indd 843 9/1/11 9:58:59 PM

 844 Section VII Idiopathic Scoliosis

Figure 82.13. (Continued) (D) Pre- and postoperative clinical photos show the marked correction of her
truncal deformity following this vertebrectomy procedure.

Figure 82.14. Thoracic kyphoscoliosis. (A) A 98-year-old boy

with neurofibromatosis. He had five prior anterior and posterior
spinal fusion attempts. He presented with a progressive kyphosco-
liotic spinal deformity with 92 of coronal plane deformity, 87
of sagittal plane deformity resulting in a combined 179 of thoracic
A kyphoscoliosis. (continued)

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 Chapter 82 Posterior Spinal Deformity Correction Techniques 845

C
Figure 82.14. (Continued) (B) He was placed in 20 lb of halo-gravity traction wherein his coronal
plane corrected to 77 and his sagittal plane to 65 in preparation for his posterior reconstruction. (C) He
underwent a posterior revision reconstruction from T1 to L3 with a three-level vertebral column resection.
At 2 years postoperative, his correction is well maintained in the coronal and sagittal planes radiographically.
(continued)

LWBK836_Ch82_p823-847.indd 845 8/26/11 5:43:16 PM

 846 Section VII Idiopathic Scoliosis
D
Figure 82.14. (Continued) (D) Pre- and postoperative clinical photos demonstrate marked correction of
his significant truncal deformity.
we place MARS above and below all three-column osteotomies.
If the distal limb translates ventrally, the MARS are used to draw
the distal limb posteriorly and reduce the subluxation.
When a three-column osteotomy is performed through a
posterior fusion mass, closure of the osteotomy can be per-
formed through a central hookrod mechanism.22 This is valu-
able in that it does not load permanent implants that will be
retained after the osteotomy is closed. Powerful force can be
applied to the spine by using this technique; however, unlike
with the three-column control afforded by transpedicular fixa-
tion, closure using a hookrod construct is associated with less
control. If using this technique, we routinely also use a track-
ing rod in the permanent implants that is not locked down to
the screws but can guide the closure and resist subluxation.
Lordosis
Some patients have pathologically severe thoracic lordosis. In
such a condition, the space available for the lungs in the chest
cavity may be compromised. If the onset of the deformity is
congenital or infantile, it can result in maldevelopment of the
lungs and chest wall. In severe cases of thoracic lordosis that are
either radiographically progressive or result in pulmonary
decline, surgery should be considered. Surgery involves seg-
mental pedicle screw instrumentation and multilevel posterior
releases with wide, multilevel SPOs. MARS are used for several
levels above and below the apex of the deformity to posteriorly
translate the spine to appropriately contoured, slightly kyphotic
rods (see Fig. 82.6). To accomplish this, a stiff 6.35-mm SS rod
LWBK836_Ch82_p823-847.indd 846
selection is ideal. Posterior translation of the thoracic spine
from a severely lordotic configuration into a sagittal kyphosis
often results in a markedly enlarged chest cavity and improved
pulmonary function tests.
CONCLUSIONS
In this chapter, we have reviewed the principles and modern
techniques of posterior spinal deformity correction. The pri-
mary technique to achieve optimal surgical results begins with
careful and thorough patient evaluation. Next, safely and
securely applied segmental pedicle screws provide the neces-
sary vertebral anchors for the myriad of available posterior-
based correction techniques. Understanding segmental
instrumentation from both a conceptual and practical stand-
point is critical as is selection of an appropriate rod in terms of
size and metal. Osteotomies, the workhorse of posterior spinal
reconstruction, must be used wisely and in the correct setting
to achieve the best outcome. Integration of the principles dis-
cussed with expertly executed technique will result in safe and
successful deformity correction.
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