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Thursday 12 April 2018



  • 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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