Tag: pedicle subtraction osteotomy

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Cervical deformity correction: comparison of neurological, radiographic, and patient-reported outcome measures by three-column osteotomy level

J Neurosurg Spine 43:433–442, 2025

Three-column osteotomy (3CO) for cervical deformity at C7–T1 is linked to higher neurological deficits, less radiographic correction, and worse Neck Disability Index outcomes compared to T2–6 levels. Surgeons should prefer 3CO below T1 when feasible for better neurological and functional results.

• Study compared outcomes of three-column osteotomy (3CO) for cervical deformity at C7–T1 vs T2–6 levels.

• Patients with 3CO at C7–T1 had higher rates of new postoperative neurological deficits (56% vs 18%).

• T2–6 3CO resulted in greater radiographic correction (T1 slope and C2–T4 SVA) than C7–T1 3CO.

• Neck Disability Index (NDI) improved after T2–6 3CO but worsened after C7–T1 3CO at 1 year.

• All patients with neurological deficits had at least partial recovery; 20% achieved complete recovery.

• 3CO level selection is multifactorial, but caudal to T1 is recommended when feasible due to better outcomes.

• Study limitations include retrospective design and single-institution data.

• Largest study to date comparing neurological, radiographic, and patient-reported outcomes by 3CO level.

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Less is more: complication rates and outcome measures of intradiscal osteotomy versus pedicle subtraction osteotomy in adult spinal deformity

J Neurosurg Spine 43:313–323, 2025

In adults with spinal deformity, intradiscal osteotomy (IDO) is as effective as pedicle subtraction osteotomy (PSO) for lordosis restoration and sagittal balance, with similar complication rates but significantly less blood loss, shorter operative time, and less postoperative back pain at 3 months.

• Intradiscal osteotomy (IDO) and pedicle subtraction osteotomy (PSO) are both used to correct adult spinal deformity, aiming to restore lumbar lordosis and sagittal balance.

• IDO and PSO showed similar fusion rates and complication profiles, with no statistically significant difference in rates of proximal junctional kyphosis, hardware failure, DVT, wound infection, or pseudarthrosis.

• IDO resulted in significantly less estimated blood loss (800 ml vs. 1400 ml) and shorter operative time (7 vs. 8.5 hours) compared to PSO.

• IDO patients reported less back pain at 3 months post-op (VAS 1 vs. 3, p=0.01) than PSO patients.

• Both techniques effectively restored lumbar lordosis, but IDO achieved better postoperative sagittal vertical axis (SVA) correction (5 cm vs. 7 cm, p=0.01).

• Higher BMI was a significant risk factor for postoperative complications in both groups.

• IDO is less technically complex, preserves vertebral body integrity, and is more familiar to spine surgeons than PSO.

• IDO can be considered an effective and potentially safer alternative to PSO for selected adult spinal deformity patients.

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Pedicle Subtraction Osteotomies for Surgical Correction of Fixed Sagittal Imbalance: A Meta-Analysis and Systematic Review

Neurosurgery 95:1223–1231, 2024

Disruption of the spine’s sagittal balance is associated with significant negative impacts on quality of life. Compared with other spinal osteotomies, pedicle subtraction osteotomy (PSO), which can potentially offer greater correction, is considered technically challenging and performed at lower rates. The aim of this study was to review the use of PSO to correct fixed sagittal imbalance and assess its efficacy and associated perioperative complications.

METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the PubMed, EBSCO host, MEDLINE, and Google Scholar databases were queried for full-text English manuscripts published from 1961 to 2022, exploring PSO for the management of fixed sagittal imbalance. Studies were included if they reported preoperative and postoperative radiographic measurements. The mean Methodological Index for Nonrandomized Studies (MINORS) for included articles was 9.6 ± 1.1. The outcomes of interest included etiology, operative time, blood loss, complications, radiographic outcomes, and patient-reported outcomes. Statistical analysis was performed using a random-effects, inverse variance-weighted meta-analysis of observational data. Pre and postoperative radiographic and clinical outcomes were compared using a Student t-test.

RESULTS: Fourteen studies with 595 patients were included. Meta-analysis showed that the mean operative time was 7.2 ± 2.0 hours, and the average blood loss was 2033 ± 629 mL. After PSO, there was a significant improvement in sagittal vertebral axis (12.41-3.92 cm, P = .0003), LL (13.35°-42.60°, P = .000002), PSO angle (5.11°to À26.91°, P = .0001), and Oswestry Disability Index (55.36-27.35, P = .02). Common complications include pseudarthrosis (8.1%), neurological deficits (7.8%), and proximal junctional failure (6.0%).

CONCLUSION: PSO offers significant correction of sagittal vertebral axis, lumbar lordosis, PSO angle, and Oswestry Disability Index scores despite its reduced utilization in recent years. Blood loss and high complication rates must be considered when evaluating the efficacy of this procedure; however, surgeon experience and operative techniques can be used to reduce morbidity.

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Asymmetrical pedicle subtraction osteotomy for correction of concurrent sagittal-coronal imbalance in adult spinal deformity

J Neurosurg Spine 33:822–829, 2020

Rigid multiplanar thoracolumbar adult spinal deformity (ASD) cases are challenging and many require a 3-column osteotomy (3CO), specifically asymmetrical pedicle subtraction osteotomy (APSO). The outcomes and additional risks of performing APSO for the correction of concurrent sagittal-coronal deformity have yet to be adequately studied.

METHODS The authors performed a retrospective review of all ASD patients who underwent 3CO during the period from 2006 to 2019. All cases involved either isolated sagittal deformity (patients underwent standard PSO) or concurrent sagittal-coronal deformity (coronal vertical axis [CVA] ≥ 4.0 cm; patients underwent APSO). Perioperative and 2-year follow-up outcomes were compared between patients with isolated sagittal imbalance who underwent PSO and those with concurrent sagittal-coronal imbalance who underwent APSO.

RESULTS A total of 390 patients were included: 338 who underwent PSO and 52 who underwent APSO. The mean patient age was 64.6 years, and 65.1% of patients were female. APSO patients required significantly more fusions with upper instrumented vertebrae (UIV) in the upper thoracic spine (63.5% vs 43.3%, p = 0.007). Radiographically, APSO patients had greater deformity with more severe preoperative sagittal and coronal imbalance: sagittal vertical axis (SVA) 13.0 versus 10.7 cm (p = 0.042) and CVA 6.1 versus 1.2 cm (p < 0.001). In APSO cases, significant correction and normalization were achieved (SVA 13.0–3.1 cm, CVA 6.1–2.0 cm, lumbar lordosis [LL] 26.3°–49.4°, pelvic tilt [PT] 38.0°–20.4°, and scoliosis 25.0°–10.4°, p < 0.001). The overall perioperative complication rate was 34.9%. There were no significant differences between PSO and APSO patients in rates of complications (overall 33.7% vs 42.3%, p = 0.227; neurological 5.9% vs 3.9%, p = 0.547; medical 20.7% vs 25.0%, p = 0.482; and surgical 6.5% vs 11.5%, p = 0.191, respectively). However, the APSO group required significantly longer stays in the ICU (3.1 vs 2.3 days, p = 0.047) and hospital (10.8 vs 8.3 days, p = 0.002). At the 2-year follow-up, there were no significant differences in mechanical complications, including proximal junctional kyphosis (p = 0.352), pseudarthrosis (p = 0.980), rod fracture (p = 0.852), and reoperation (p = 0.600).

CONCLUSIONS ASD patients with significant coronal imbalance often have severe concurrent sagittal deformity. APSO is a powerful and effective technique to achieve multiplanar correction without higher risk of morbidity and complications compared with PSO for sagittal imbalance. However, APSO is associated with slightly longer ICU and hospital stays.

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Cervical Spine Deformity—Part 3: Posterior Techniques, Clinical Outcome, and Complications

Neurosurgery 81:893–898, 2017

The goals of cervical deformity surgery include deformity correction, restoration of horizontal gaze, decompression of neural elements, spinal stabilization with a biomechanically sound construct, and meticulous arthrodesis technique to prevent pseudoarthrosis and minimizing surgical complications.

Many different surgical options exist, but selecting the correct approach that ensures the optimal clinical outcome can be challenging and often controversial. In this last part of the cervical deformity review series, various posterior deformity correction techniques are discussed in detail, along with an overview of surgical outcome and postoperative complications.

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Cervical Spine Deformity—Part 2: Management Algorithm and Anterior Techniques

Neurosurgery 81:561–567, 2017

A sound operative plan based on solid understanding of the pathology and biomechanics is the most important part of cervical deformity correction.

Many different surgical options exist for operative management of cervical spine deformities. However, selecting the correct approach that ensures the optimal clinical outcome can be challenging and often controversial.

In Part 2 of this three-part review series, we discuss the pre-operative planning, management algorithm, and anterior surgical techniques for cervical deformity correction.

 

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Correction of severe spinopelvic mismatch: decreased blood loss with lateral hyperlordotic interbody grafts as compared with pedicle subtraction osteotomy

Neurosurg Focus 43 (2):E15, 2017

Pedicle subtraction osteotomy (PSO) provides extensive correction in patients with fixed sagittal plane imbalance but is associated with high estimated blood loss (EBL). Anterior column realignment (ACR) with lateral graft placement and sectioning of the anterior longitudinal ligament allows restoration of lumbar lordosis (LL). The authors compare peri- and postoperative measures in 2 groups of patients undergoing correction of a sagittal plane imbalance, either through PSO or the use of lateral lumbar fusion and ACR with hyperlordotic (20°–30°) interbody cages, with stabilization through standard posterior instrumentation in all cases.

METHODS The authors performed a retrospective chart review of cases involving a lumbar PSO or lateral lumbar interbody fusion and ACR (LLIF-ACR) between 2010 and 2015 at the authors’ institution. Patients who had a PSO in the setting of a preexisting fusion that spanned more than 4 levels were excluded. Demographic characteristics, spinopelvic parameters, EBL, operative time, and LOS were analyzed and compared between patients treated with PSO and those treated with LLIF-ACR.

RESULTS The PSO group included 14 patients and the LLIF-ACR group included 13 patients. The mean follow-up was 13 months in the LLIF-ACR group and 26 months in the PSO group. The mean EBL was significantly lower in the LLIF-ACR group, measuring approximately 50% of the mean EBL in the PSO group (1466 vs 2910 ml, p < 0.01). Total LL correction was equivalent between the 2 groups (35° in the PSO group, 31° in the LLIF-ACR group, p > 0.05), as was the preoperative PI-LL mismatch (33° in each group, p > 0.05) and the postoperative PI-LL mismatch (< 1° in each group, p = 0.05). The fusion rate as assessed by the need for reoperation due to pseudarthrosis was lower in the LLIF-ACR group but not significantly so (3 revisions in the PSO group due to pseudarthrosis vs 0 in the LLIF-ACR group, p > 0.5). The total operative time and LOS were not significantly different in the 2 groups.

CONCLUSIONS This is the first direct comparison of the LLIF-ACR technique with the PSO in adult spinal deformity correction. The study demonstrates that the LLIF-ACR provides equivalent deformity correction with significantly reduced blood loss in patients with a previously unfused spine compared with the PSO. This technique provides a powerful means to avoid PSO in selected patients who require spinal deformity correction.

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The Mini-Open Pedicle Subtraction Osteotomy for Flat-Back Syndrome and Kyphosis Correction

Operative Neurosurgery 12:309–316, 2016

The pedicle subtraction osteotomy (PSO) has been a mainstay treatment for flat-back syndrome. The morbidity of open deformity correction can be high, and minimally invasive applications may reduce such morbidity.

OBJECTIVE: To describe an operative technique of the mini-open PSO.

METHODS: Two patients underwent percutaneous fixation above and below the PSO, and the PSO was performed in a mini-open fashion. The correction was obtained by cantilever.

RESULTS: The patient who underwent the L3 PSO had a prior fusion from T11 to L4 for scoliosis 35 years ago. On presentation at 62 years of age, he had a pelvic incidence of 54, lumbar lordosis of 23, sagittal vertical axis of 114 cm, and pelvic tilt of 25. He underwent an anterior lumbar interbody fusion at L5-S1 followed by a min-open L3 PSO. He had a postoperative lumbar lordosis of 64 (correction of 41), and his sagittal vertical axis went to 13 cm. His Oswestry Disability Index and visual analog scale scores decreased after surgery. The second patient was 64 years of age and underwent an L1 PSO. He had 43 of kyphosis from T10 to L2. He had a preoperative pelvic incidence of 63, lumbar lordosis of 35, pelvic tilt of 24, and sagittal vertical axis of 3 cm. His postoperative kyphosis improved from 43 to 32.

CONCLUSION: The mini-open PSO can achieve significant lordosis, although it is heavily reliant on anterior arthrodesis. Larger studies are needed to compare this approach with an open PSO.

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Sagittal plane correction in pedicle subtraction osteotomy

Sagittal plane correction in pedicle subtraction osteotomy

J Neurosurg Spine 19:507–514, 2013

The Xia 3 SUK Direct Vertebral Rotation (DVR) System was developed for performing the vertebral derotation maneuver in scoliosis surgery. The author applied this device to sagittal plane correction in pedicle subtraction osteotomy for adult spinal deformity.

The surgical procedure included 1) preparing secure proximal and distal foundations for correction using mutisegmental pedicle screw-rod fixation (to avoid stress concentration to a specific screw-bone interface), 2) decancellating only the posterior two-thirds of the vertebral column, 3) providing supplemental interbody fusion above and below the osteotomy site (the anterior one-third of the vertebral column and interbody cages serve as an anterior column support and a pivot of correction), 4) closing the osteotomy by gradual approximation of SUK tubes secured to the proximal- and distal-most screw heads, and 5) connecting rods between the proximal and distal screw-rod constructs.

Eight consecutive patients with fixed sagittal imbalance were treated using this surgical procedure. No patient required distal fixation points extending to the sacrum and/or pelvis. The sagittal plane correction was 43°. The mean anterior deviation of the C-7 plumb line was improved from 12.7 cm to 4.0 cm immediately after surgery, and it was 6.0 cm at the final follow-up.

A pedicle subtraction osteotomy using the Xia 3 SUK DVR System ensures a safe and secure sagittal plane correction in adult spinal deformity.

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