Pedicle subtraction osteotomy in the treatment of chronic, posttraumatic kyphotic deformity

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Object

Thoracolumbar fractures, treated operatively or nonoperatively, may cause painful kyphotic deformities over time. A pedicle subtraction osteotomy (PSO) is a single-stage posterior procedure designed to correct sagittal plane deformity. Although it was initially used to treat nontraumatic conditions, a PSO can be highly effective in chronic, posttraumatic fractures of the lumbar spine. In this report the authors review details obtained in the treatment of three patients with severe, posttraumatic spinal deformities. They describe the surgical technique used to correct the sagittal malalignments.

Methods

All three patients were middle aged, and good bone mineral density had been demonstrated in each case preoperatively. After PSO, a mean 51° improvement in sagittal alignment was achieved and maintained until a solid arthrodesis was documented in each case. Substantial improvements in pain relief and functional outcome were observed. A detailed, procedure-specific literature review was undertaken.

Conclusions

A PSO is a valuable tool to add to the armamentarium of neurosurgeons who treat patients suffering from painful posttraumatic deformity following fractures of the upper lumbar spine.

Abbreviations used in this paper:AP = anteroposterior; AS = ankylosing spondylitis; BMD = bone mineral density; CT = computed tomography; EBL = estimated blood loss; PS = pedicle screw; PSO = pedicle subtraction osteotomy; VAS = visual analog scale; VB = vertebral body.

Article Information

Address reprint requests to: Robert F. Heary, M.D., Department of Neurological Surgery, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, 90 Bergen Street, Suite 8100, Newark, New Jersey 07103. email: heary@umdnj.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 1. Radiographic studies. A: Preoperative lateral standing radiograph demonstrating a 26° focal kyphosis from the superior aspect of L-2 to the inferior aspect of L-3. B: Preoperative three-dimensional CT scan. C: Postoperative lateral standing 36-in radiograph taken 2 years after an L-2 PSO, showing an improvement in the sagittal alignment to 7° of lordosis (from the top of L-2 to bottom of L-3), representing a 33° overall correction.

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    Case 2. A and B: Preoperative AP and lateral standing 36-in radiographs documenting the absence of significant coronal malalignment; however, a focal 49° kyphosis is present from the top of T-12 to the bottom of L-2. C and D: Postoperative AP and lateral standing 36-in radiographs obtained at the 2-year follow up. In the AP view (C) good alignment has been maintained and a generous quantity of bone graft is present in the lateral gutters bilaterally. In the lateral image (D) 5° of kyphosis from T-12 to L–2 is present, indicating a 44° overall improvement in sagittal alignment.

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    Case 3. A: Lateral preoperative radiograph showing a 54° kyphosis from the top of L-1 to the bottom of L-3. B: Intraoperative photograph obtained following the removal of all L-2 posterior elements including the spinous process, bilateral laminae, the pars interarticularis, superior and inferior facet joints, and the transverse processes bilaterally. The inferior aspect of the L-1 lamina and the superior aspect of the L-3 lamina have been removed, and the L-2 pedicles have been resected. The thecal sac and L-2 nerves are widely decompressed. The distance between the L-1 PSs and the L-3 PSs is 6.5 cm. The compressor is positioned between the L-1 and L-3 PSs. C: Intraoperative photograph acquired after compression was created with a contralateral temporary plate to maintain the correction. Note that the distance between the L-1 and L-3 PSs is now 3 cm, and the spinous processes of L-1 and L-3 are nearly in contact. D: Intraoperative photograph obtained following placement of bilateral rods, implantable bone stimulator, superior and inferior cross-connectors, and a generous quantity of autologous bone graft. Note that additional L-1 and L-3 resection has been performed and the redundant dura mater is visible. E: Lateral standing 36-in plain radiograph taken 2 years postoperatively of a 23° lordotic curvature from L-1 to L-3 representing a 77° correction in sagittal alignment compared with the preoperative view (A).

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