CORRECTIVE OSTEOTOMIES OF SPINE

CORRECTIVE OSTEOTOMIES OF SPINE

• used to treat sagittal and coronal imbalances of spine in patients with variety of spinal deformities
• two general types of spinal imbalances
  • type I
    • segmental or regional imbalance – spine have overall balance
  • type II
    • global imbalance
      • unable to compensate for deformity
      • patient flex hip and knee to maintain proper balance and horizontal gaze

• balanced spine : plumb line from C7 falls over L5-S1 disc
  • if falls anteriorly : positive sagittal balance
  • if posteriorly : negative sagittal balance
• sagittal plane imbalance - one or more osteotomies manipulating balance of spine – by shortening or lengthening anterior or posterior column – to obtain specific correction
• osteotomy done as treatment in
  • fixed adult scoliosis
  • imbalance of spine in sagittal plane
  • spondyloptosis
  • spondyloarthropathies : ankylosing spondylitis, psoriatic arthropathy

Types of corrective osteotomies

• Smith – Peterson Osteotomy (Posterior element wedge resection)
  • originally used in kyphotic deformity in ankylosing spondylitis
  • done in thoracic spine
  • can be done at multiple levels
  • indications
    • in fixed imbalance in sagittal plane of spine d/t loss of lumbar lordosis : idiopathic scoliosis
    • degenerative imbalance in sagittal plane : older individuals
  • patient on open frame spine table – prone position – patient flexed initially
  • identify the level
  • lamina, ligamentum flavum, superior and inferior articular process removed bilaterally
  • 1mm resection : 1⁰ correction
    • maximum 10⁰ correction obtained at one level
    • maximum 30⁰ correction obtained when done at multiple level
  • open disc space is a pre requisite
  • can not be done at a level at which a spinal arthrodesis has been previously performed
  • if disc is collapsed it affects amount of correction
  • extend the patient to close the osteotomy
  • fix the osteotomy with pedicle screws and rods
  • neural elements should be free
  • complications
    • major neurological complications can occur after any type of osteotomy – wake up test after closing the osteotomy site is the most accurate way to assess the neurological failure
    • intraspinal hematoma
    • intestinal obstruction, Superior mesentric artery syndrome
    • superficial wound infection
    • substantial coronal imbalance
    • injury to major vessels d/t stretching (rare)
• Pedicle subtraction osteotomy (Posterior three column wedge resection)
  • performed at L2 or L3 level
    • apex of normal lumbar lordosis
    • this level caudal to conus medullaris – minimize neurological injury
  • indications
    • ankylosing spondylitis
    • deformities with apex in lumbar spine
    • in circumferential fusion along multiple vertebrae which prevent doing Smith Peterson osteotomy
  • increased lumbar lordosis created to compensate for thoracic kyphosis
  • involves transpedicular vertebral wedge resection extending from the posterior elements through the pedicles – into anterior cortex of the vertebral body
  • when middle and posterior column defects are closed – length of anterior cortex remains unchanged
  • pedicle subtraction osteotomy can achieve - ~30-40⁰ of lordosis at each level of osteotomy performed
  • complications
    • technically demanding
    • deep wound infections
    • pulmonary embolism
    • pneumonia
    • MI
    • increasing age is a significant predictor of complications
• Cervical extension osteotomy
  • not only to correct sagittal balance but also to correct horizontal gaze
  • esp in ankylosing spondylitis
  • indications
    • correct cervical flexion deformity by ankylosing spondylitis or trauma
    • visual field impairment to see ahead (horizontal gaze)
    • elevate chin from sternum to improve appearance and ability to eat
    • prevent atlanto axial subluxation or dislocation
    • relieve tracheal or esophageal distortion causing dyspnoea and dysphagia
    • prevent irritation of cord or excessive traction of nerve roots
  • angle of chin brow to vertical line calculated
    • to determine amount of correction needed
    • to determine the size of wedge to be removed from posterior aspect of cervical spine
  • 1mm bone resection : ~ 1-2⁰ correction
  • usually done at C7 level
  • two methods
    • removal of posterior elements(spinous process and lamina) and pedicles – vertebral osteotomy not done
    • transpedicular osteotomy where vertebral body osteotomy also done
  • complications
    • spinal cord or nerve root compressed if enough bone not removed
    • instability or subluxation at osteotomy site
    • non union
    • over correction of deformity can overstretch trachea or esophagus and produce obstruction
• Vertebral column resection
  • defined as resection of one or more vertebral segments including posterior elements, pedicles, vertebral bodies, disc
  • for the treatment of spinal column tumors, spondyloptosis, congenital kyphosis, hemivertebral resection
  • only when deformity not amenable to other osteotomy techniques – in severe and rigid imbalances
  • indications
    • congenital kyphosis
    • hemivertebra
    • L5 spondyloptosis
    • resection of spinal tumor
  • vertebral body completely removed
  • reconstruction needed after resection
    • metal cage or structural autograft or allograft used
    • supplemented with pedicle screws and rods
  • arthrodesis of spine (equal to length of instrumentation) done to stabilize the spine
  • complications
    • complete paralysis
    • hemopneumothorax
    • proximal junctional kyphosis
    • radicular pain
    • pseudoarthrosis

Selection of correct osteotomy and level

• osteotomy done at the region of relative kyphosis and maximum deformity
• Smith Peterson if correction needed <30⁰
• >30⁰ pedicle subtraction osteotomy done
• sagittal deformity with coronal imbalance : asymmetric pedicle subtraction osteotomy or vertebral column resection

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