1. Adult Spinal Deformity Planning Your Osteotomy
Eric Klineberg, MD
Assistant Professor
Department of Orthopaedics
UC Davis
Surgical Management of Adult Spinal Deformity
February 16, 2013
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2. I have no financial interest with any company regarding this subject
Speaking:
AO, DePuy Synthes Spine
Fellowship Funding:
DePuy Synthes Spine, OREF
Grants:
AO Foundation
I have no financial interest with any company regarding this subject
Eric Klineberg, MD
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3. Lecture Outline Patient and Surgeon analysis Identify the problem
Identify the solution
Execute
Deal with complications
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4. Surgical Decision Making
Patient medical status
Surgeon experience
Minor or Major deformity
Gradual or sharp kyphosis
Prior fusion
Flexability

5. Patient Factors Age Prior surgery Co-Morbidities
Diabetes, HTN, Cardiac dz (stents, MI etc…)
Modifiable risk factors:
Obesity
Smoking
Osteoporosis

6. Obesity Increasing size, makes surgical exposure more difficult
More blood loss
Risk for PE, poor mobilization
Need to have threshold for BMI
Patients can meet us “half way”

7. Smoking Nicotine has been shown to decrease wound and bone healing
Even with new biologics
I am very aggressive getting patients to stop: CHANTIX®, WELLBUTRIN®
Can check urine nicotine levels
All patients will try to stop, but few actually will. However even a modest decrease can be helpful

8. Osteoporosis This is becoming the largest problem in my practice!
Bisphosponates, Calcitonin, estrogen replacement.
DEXA on all pre-op patients for baseline
T < -3.0 will try to initiate FORTEO® (PTH analog)
Only medication that increases bone formation
Expensive and can be difficult without prior failure

9. Surgeon Factors Experience, experience, experience!
Location, location, location!
Help available
New practice, don’t want complications!
Setting: academic, private, in-between
What does your hospital have for you?
Bed, equipment, rep, implants, (unanticipated implants), ICU, residents, fellows, NP, PA

10. Osteotomies in the posterior-only treatment of complex adult spinal deformity: a comparative review. Dorward, IG, Lenke, LG, JNS Mar 2010

11. Adult Scoliosis
What radiographic parameters do we need to consider when evaluating a scoliosis patient?
What makes a difference for our patients?

12. Common Radiographic Findings
Use similar measurements as for pediatric population
Are we missing out on adult deformity?
Emphasis on pelvic alignment
Pelvic and spinal miss-alignment

13. Radiographic Measurements
Coronal
Cobb angles
CSVL
Major and Minor curves
Sagittal
Sagittal vertical axis (SVA)

14. Radiographic MeasurementsPI LL TK
SVA
Pre-operative and post-operative sagittal spino-pelvic parameters
Measurements:
SVA,
L1-S1 Lordosis,
T4-T12 Thoracic Kyphosis,

15. Normal Values Mean Lumbar Lordosis = 40-60°
Mean Thoracic Kyphosis = 10-40°
Avg normal SVA = < ± 2.5 cm
Recently Schwab et al. have talked about Center of Gravity line

16. Radiographic MeasurementsPT LL TK
Pelvic Measurements:
Pelvic Tilt
Pelvic Incidence
This is pelvic morphology, it does not change
Pelvic MisMatch
Pelvic Incidence – Lumbar Lordosis

17. Radiographic Measurements
Pelvic MisMatch
Pelvic Incidence – Lumbar Lordosis
To maintain balance want PI-LL = 10deg

18. Radiographic Measurements
Pelvic MisMatch
Pelvic Incidence – Lumbar Lordosis
Increased PI leads to Increased LL

19. Radiographic Measurements
Pelvic MisMatch
Pelvic Incidence – Lumbar Lordosis
Decreased PT leads to Decreased LL
Pelvic Tilt Increases

20. Radiographic Measurements
With Deformity

21. Radiographic Measurements
With Deformity
Positive SVA

22. Radiographic Measurements
With Deformity
Positive SVA
Decreased PT
Pelvic retroversion
Decreased LL
PI-LL

23. Radiographic Measurements
With Deformity
Positive SVA
Decreased PT
Pelvic retroversion
Decreased LL
PI-LL
Decompensated Deformity

24. Common Radiographic Findings
Three commons findings:
L3–L4 rotatory subluxation,
L4–L5 tilt
L5–S1 disc degeneration
Bridwell et al 2002

25. Adult Scoliosis
Restoration of the sagittal plane in the setting of adult deformity surgery is critical to achieving long term clinical success.
Glassman et al suggested that a positive sagittal balance was the most reliable predictor of clinical symptoms in adult deformity patients.
Schwab et al demonstrated that focal obliquity and loss of lumbar lordosis were significantly correlated with pain and negative outcomes.
Glassman SD, et al. Correlation of radiographic parameters and clinical symptoms in adult scoliosis. Spine 2005;30:682–8.
Schwab FJ, et al. Adult scoliosis: a quantitative radiographic and clinical analysis. Spine 2002;27:387–92

26. Adult Scoliosis
Pelvic tilt defines the amount of pelvic retroversion and has been implicated as an important factor on postoperative residual pain.
Lazennec at el described a decrease in residual pain with lower pelvic tilt, indicating less retroversion and potentially less pelvic compensation.
This concept was more clearly defined by Lafage et al, and a pelvic tilt of less then 25 degrees was established as optimal.
Lazennec JY, et al. Sagittal alignment in lumbosacral fusion Eur Spine J 2000;9:47–55.
Lafage V, et al. Pelvic tilt and truncal inclination: two key radiographic parameters Spine Aug 1;34(17):E

27. Classification System
AIS classification system (King & Lenke) cannot be applied.
These are different curves
Stiffer, degenerative processes
Often have clinical symptoms at presentation
natural history is different
Recently, SRS developed classification for adult deformity.

28. ASD Classification

29. SRS Classification for Adult Deformity
Curve Type
Defines the primary deformity
Modifiers
PI-LL: miss-match
Pelvis defines what is needed
PT: amount of compensation
Compensatory retroversion
SVA: amount of global decompensation
Marker of overall decompensation (does not take into account cervical spine)

30. Spine Balance
Most important principle in the surgical treatment of adult scoliosis
Achieve & maintain proper sagittal & coronal balance
Head placed over the pelvis.

31. Spine Balance A balanced spinal posture provides for
decreased energy requirements with ambulation
limits pain and fatigue
improves cosmesis and patient satisfaction
limits complications associated with unresolved (or new) deformities

33. SVA = 11
LL=+31
TK=0

34. SVA = 11
LL=+31
TK=0
PT = 26
PI = 60
Mismatch =
= 91

35. Osteotomies in the posterior-only treatment of complex adult spinal deformity: a comparative review. Dorward, IG, Lenke, LG, JNS Mar 2010

36. How to Achieve Correction
Surgical planning
Determine ammout of correction needed
Flexibility of the curves
Prone films, exam, CT/MRI

37. How to Achieve Correction
Posterior
Facetectomy, Ponte, osteotomy, vertebral column resection
Anterior
Discectomy, and interbody
Lateral
Discectomy
ALL release

38. How do I decide Determine flexibility If flexible – posterior only
If fused – osteotomy
If stiff
Good LL (20-30) posterior only
Poor LL – anterior posterior (particularly with High PT)

39. Anterior/Posterior Lateral ALL release
Usually for adjacent level disease with prior fusion
Flat back deformity

40. Anterior/Posterior Lateral ALL release
Usually for adjacent level disease with prior fusion
Flat back deformity

42. SVA = 11
PT = 25
LL=+31
TK=0
PI = 60

43. Goal To Achieve normal alignment: SVA < 4cm PT = 20 PI-LL = 10
Need 70 deg of lordosis at end + starting at 30 degrees positive, and has high pelvic tilt
Need more then 90 degrees of correction!
Formal Anterior/Posterior

44. SVA = 0
PT = 14
LL=67
TK=40
PI = 60
PI-LL = 10

50. Technique Positioning Prone (I use open frame, OSI table)
Arms are up, may put arms at side for high Costotransversectomy (>T4)
Neuro-monitoring is a must!
Wide prep for possible Chest tube if you enter pleural space during dissection

51. Ponte/Smith-Petersen Osteotomy
History
In 1945, Smith-Petersen et al. reported the first spinal osteotomy.
Most studies reported the correction in ankylosing spondylitis patients with osteoclasis
Ponte described similar bone resection and mobility through an open disc space

52. Ponte/Smith-Peterson Osteotomy
SPO allows for 10° per level
Remove supraspinous, intraspinous, and ligamentum flavum with facetectomy to produce a posterior release.
Ensure exiting nerves are decompressed
Posterior compression of the osteotomy brings about kyphosis correction

53. Osteotomy The overall effect is similar to a Smith-Peterson Osteotomy
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55. Anterior release, combined with SPO

56. Pedicle Subtraction Osteotomy
History
Pedicle subtraction osteotomy was first described by Thomasen in 1985
This is an extension of the SPO, and involves resection of the posterior elements and vertebral body
Particularly useful when anterior approach is not possible

57. Pedicle Subtraction Osteotomy
Typically performed in the lumbar spine
Larger correction
Can shorten cauda
Less often in cervical and thoracic spine
Bony resection determines final alignment

58. PSO Set up Neuromonitoring
Measure pre-op, must include pelvic parameters
Plan, plan , plan
Expect blood loss:
Cell saver, coagulant (TXA, Amicar), blood products

59. PSO - Technique Exposure Careful with blood loss Place screws first
If excessive bleeding (>2L, before PSO, plan on staging)
Instrumentation removal etc…

60. PSO - Technique Decompress level that you need – L3
Often scar tissue etc…
Remove Lamina above at minimum for adequate exposure (L2-3)
Identify exiting nerves at level (L3) and level above (L2)
Dissect pedicle to pedicle (L2-4)

61. PSO - Technique +/- remove transverse process Remove body first
Then lateral body (I dissect laterally using cobb, and place malleable retractor)
Medial pedicle and posterior body is last
MUST remove all posterior body (will cause neurologic injury)

62. PSO - Technique Over contour rods Multiple techniques: 4 rod
Cantilever bend
Bed reduction

63. PSO - Technique Dura will buckle Verify nerves are free in new foramen
Feel under the dura
Check signals

66. Vertebral Column Resection
History
VCR was first described in 1922 by MacLennan, who performed an apical resection from a posterior-only approach with postoperative casting for the treatment of severe scoliosis
In 1983, Luque presented eight cases of vertebrectomy in patients with a primary spinal deformity > 90°
In 2002, Suk et al. developed the posterior-only approach for VCR (PVCR)

67. Where are we trying to go?
Costotransversectomy and VCR provide both access to the vertebral column in the thoracic spine
Costotransversectomy allows for access on usually one side to proved decompression of the neural structures
VCR is usually a costo that is expanded to both sides to destabilize the spine and allow for coronal and sagittal re-alignment

68. Thoracic Vertebrae Osseous anatomy Spinous process Lamina Pedicle Pars
Transverse Process
Rib Articluations
What Vertebra does the T9 rib articulate with?

69. Thoracic Vertebrae Critical to understand the rib articulation:
Ribs articulate with the transverse process of their vertebra, as will as the body of their vertebra, and the level above.
Therefore to get access to both disc levels you usually need to take two ribs…

70. Rib Articluation
Thoracic Surgery Clinics Volume 17, Issue 4, November 2007, Pages 473–489

71. Spinal Cord
Spinal Cord
Intercostal Nerve

72. Neurovascular Bundle
Neurovascular bundle runs on the inferior aspect of the rib in the neurovascular groove

73. Technique Positioning Prone (I use open frame, OSI table)
Arms are up, may put arms at side for high Costotransversectomy (>T4)
Neuro-monitoring is a must!
Wide prep for possible Chest tube if you enter pleural space during dissection

74. Case Example 31 yo female Biopsy diagnosis of metastatic gastric CA
c/o back pain and LE parasthesia
PE: pathologic clonus, hyper-reflexia, pain with back percussion

75. Case T9 T9
T11

76. Technique Perform standard midline approach
Dissection carried out to TP on both sides
Extend dissection laterally on planned Costotransversectomy side – need 6-8cm of ribs
Place all pedicle screws
Temporary rod

77. Technique Laminectomy
Can be unilateral, but I usually perform full laminectomty for better visualization
Ligate exiting root from foramen (use ties on both sides and leave long)

78. Technique Will need to take two ribs
Preserve intercostal artery and vein if possible
Use periosteal to separate pleura and NVB from rib
Disarticulate ribs from TP and vertebra
Then remove TP and pedicle

79. Technique Place retractor to ventral surface of vertebra
Identify disc space (use rib head)
Nerve ties can be used for gentle retraction

80. Technique Proceed with vertebra decompression
Start with body first identify disc space and work towards the middle.
Medial bony ledge is taken last
Watch out for epidurals

81. Technique Leave ALL and anterior vertebra wall (protection)
Place corpectomy device
Compress with posterior instrumentation

82. Intra-Operative

83. Post-Operative

84. Surveillance CT

85. Costotransversectomy
Complications:
Pleural Tear
Chest tube vs red-rubber catheter
(I usually place Chest Tube)
Dural Tear
Primary repair, if not possible, may need shunt

86. Vertebral Column Resection
Costotransversectomy on both sides
May need to resect both nerve roots
May want to clamp intercostal artery if you need to ligate (adamkiewitcz)

87. Technique (stole from AONA)
Midline Incision
Laminectomy
Resection of posterior rib, TP, Facet
Sacrifice of nerve roots
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88. Technique (stole from AONA)
Temporary Rod
Corpectomy
Kyphocorrection
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89. Technique (stole from AONA)
Definitive Rods
Compression across cage
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93. Tips and Tricks Neuromonitoring is a must!
Be careful with shortening the spinal column
Use cage (+/- expandable)
Translation causes paralysis!
Keep anterior column intact, do not remove ALL and eggshell anterior cortex (like PSO)

94. Tips and Tricks Nerve root ties can be used at gentle retractors
Use rib head to define the disc space
Work from disc space to disc space
Prep wide for possible chest tube
(warn patient ahead of time)
Pre-operative planning is the key
measure twice and cut once.

95. Thank You
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