CHAPTER
Brian A. OShaughnessy
95
Pedicle Subtraction Procedures
for Complex Spinal Deformity
INTRODUCTION
Pedicle subtraction osteotomy (PSO) is a powerful surgical
technique for the treatment of fixed spinal deformity. The
primary advantage of PSO is that it allows posterior-only
correction of fixed deformity and obviates the need for an ante-
rior release and its associated morbidity.6,17 Previously pub-
lished data have demonstrated that approximately 30 to 40 of
focal lumbar lordosis can be introduced using this tech-
nique.1,2,5,9,10,12,19,20 An asymmetric wedge resection can be car-
ried out such that a two-plane sagittal/coronal correction is
acquired. Although earlier papers on similar osteotomy tech-
niques were published by other authors,8,11 the origin of PSO is
frequently credited to the work of Thomasen18 and his treat-
ment of sagittal imbalance in ankylosing spondylitis. Modern
appreciation for the importance of sagittal balance, particularly
in the setting of flatback deformity, has brought about a sig-
nificant amount of recent interest in this technique. A multi-
tude of technical descriptions of lumbar PSO as well as clinical
reviews on the subject have recently emerged.3,15,16 Most reports
show that excellent sagittal restoration achieved with PSO is
often accompanied by similarly favorable clinical outcomes as
determined by validated questionnaires.
In this chapter, we describe our technique for performing a
lumbar PSO. In addition, we review some of the recent litera-
ture on patients treated with PSO and discuss relevant topics of
interest including sagittal/coronal correction, pseudarthrosis
rates, and surgical methods to prevent a nonunion. Perioperative
complications and their management/avoidance are described.
Finally, the chapter is concluded with some data regarding tho-
racic PSOs and the limitation of this strategy for the treatment
of fixed thoracic deformity.
INDICATIONS FOR LUMBAR PSO
The most common indication for a lumbar PSO is fixed sagittal
imbalance. Patients usually have regional lumbar hypolordosis
in conjunction with global sagittal imbalance. The causes of
such a deformity are multiple; however, iatrogenic etiologies
are the most common. Idiopathic scoliosis previously treated
with Harrington distraction instrumentation is a classical cause
of fixed flatback deformity. Advanced degenerative lumbar
LWBK836_Ch95_p987-998.indd 987
Jacob M. Buchowski
Keith H. Bridwell
spondylosis, thoracolumbar fracture, and prior laminectomy
are all additional causes of kyphosis that, depending on the
severity and rigidity of the deformity, might be treated most
effectively with PSO.
One of the most important considerations when evaluating
a patient as a candidate for PSO is the rigidity of the deformity.
PSO is not indicated if potentially less morbid osteotomies,
such as Smith-Petersen osteotomies (SPOs) can achieve the
same or similar correction and render the patient a balanced
spine (Table 95.1). Most patients who benefit from a PSO
require at least 30 of additional lumbar lordosis and 7 to 10 cm
of correction to their sagittal vertical axis. This notwithstand-
ing, even very severe sagittal deformities, if mobile, can often
be corrected with SPO or Ponte osteotomies.5,15 These poste-
rior facet-based osteotomies are most effective in the setting of
large disc spaces that are not ankylosed anteriorly. Preoperative
lateral long cassette radiographs with the patient in hyperex-
tension over a bolster is often valuable in determining the
degree of sagittal curve mobility. Although not routinely
obtained, a computerized tomography (CT) scan can also be
quite valuable in determining whether facet osteotomies will
offer enough sagittal correction to reorient the patient. If the
preoperative CT scan reveals collapsed disc spaces and bridg-
ing anterior osteophytes, facet osteotomies are unlikely to yield
reliable correction. Of course, PSO or another type of three-
column osteotomy such as a vertebral column resection (VCR)
is the most desirable method to treat a patient with fixed sagit-
tal deformity and surgical anterior column fusion.
LUMBAR PSO: OPERATIVE TECHNIQUE
Patients are appropriately padded and positioned prone on a
Jackson table with their hips extended. Neurophysiologic mon-
itoring with somatosensory evoked potentials (SSEPs) and neu-
rogenic mixed evoked potentials (NMEPs) or transcranial
motor evoked potentials (tcMEPs) for motor assessment are
used in all cases. Electromyography (EMG) may also be used
for nerve root monitoring during the procedure, although the
efficacy of this monitoring modality has been questioned. After
routine subperiosteal exposure of the posterior spinal elements
and removal of any indwelling instrumentation in revision
cases, pedicle screws are placed above and below the level of
987
8/26/11 3:06:20 PM
 988 Section VIII Adult Spinal Deformity

Advantages/Disadvantages
TABLE 95.1 of One PSO Versus Multiple
SPOs
Advantages of One PSO
Performed at a single segment
Correction is highly predictable and independent of disc height
Can be performed in the setting of anterior column ankylosis
Less prone to cause coronal decompensation than multiple
SPOs
Less force on bonescrew interface to close osteotomies than
multiple SPOs
Disadvantages of One PSO
Less harmonious kyphosis correction than multiple SPOs
Can witness spinal subluxation during osteotomy closure
Greater acute blood loss performing the osteotomy than with
multiple SPOs
More biomechanically unstable than multiple SPOs
Higher risk of nerve injury than multiple SPOs

PSO, pedicle subtraction osteotomy; SPO, Smith-Petersen

osteotomy.

the PSO. Transpedicular fixations points at least two to three

levels above and below the osteotomy are required for optimal
spinal control. Lumbar PSOs are typically performed at either
L2 or L3, and therefore in the setting of sagittal balance correc-
tion, instrumentation often spans from at least T10 or T11 down
to the sacrum and ilium.
Prior to any bone removal, a pedicle preparatory hole can
be placed at the level of the PSO to maintain orientation while
the osteotomy is being carried out. This is feasible if there are
enough discernible posterior bony landmarks which is not
always the case. The osteotomy is begun with a central laminec-
tomy extending from the inferior pole of the cephalad pedicles
to the superior pole of the caudad pedicles (Fig. 95.1). A cen-
tral laminectomy in excess of the posterior laminar closure
goals is always performed in order to allow for dural redun-
dancy and avoid any neural impingement during osteotomy
closure. The laminectomy is widened bilaterally to expose the
nerve roots exiting below the pedicles being resected. The infe-
rior facets at the level of the PSO and the level above the PSO
are then removed with an osteotome or high-speed drill. The
superior facet and top of the pedicle at the level of the PSO are
then partially resected using either a Leksell rongeur or high-
speed drill. Excellent visualization of the nerve roots at the
level of the PSO is then feasible.
It is useful at this point to use Kerrison rongeurs to remove
bone flush with the inferior margin of the pedicle cephalad to
the PSO to expose this superiorly exiting nerve root. The nerve
root exiting beneath the cephalad pedicle as well as the root
exiting at the level of the PSO will share the same super-
foramen at the end of the resection, and it is therefore useful
to ensure that they are both free of any undue compression.
The root above, once visualized and palpated to be free of com-
pression, can be kept in the tuft of perineural fat and soft tissue
that supports its position under the pedicle and prevents it
from drifting caudally into the region of the PSO. Although not
studied scientifically, keeping this soft tissue cuff around the
superior root may also partially preserve its blood flow and limit
transient peripheral neural palsy.
Figure 95.1. A wide laminectomy is performed extending from
the inferior pole of the cephalad pedicles to the superior pole of the
caudad pedicles. (Reprinted with permission from Bridwell KH, Lewis
SJ, Rinella A, Lenke LG, Baldus C, Blanke K. Pedicle subtraction
osteotomy for the treatment of fixed sagittal imbalance. Surgical
technique. J Bone Joint Surg Am 2004;86:4449.)
At this point in the procedure, exposure of the lateral verte-
bral body wall is performed. There is variation in technique
based upon whether the PSO is being done in a primary sur-
gery or if there is a posterolateral fusion mass. In the case of a
primary surgery, the point of connection between the trans-
verse process (TP) and lateral pedicle is severed. This is easily
done with a high-speed drill. Alternatively, Penfield dissectors
and/or a Woodson elevator can be used to strip the insertion of
the transversalis membrane from the TP and a Kerisson ron-
geur can be used to disconnect the TP from the lateral pedicle.
With the lateral stump of the pedicle exposed, a Penfield No. 1
dissector is used to develop a subperiosteal plane along the lat-
eral vertebral body wall. The segmental vessels are carried later-
ally in this dissection. Venous bleeding during this stage is dealt
with using bipolar electrocautery. In addition, prothrombotic
substances such as FloSeal (Baxter U.S., Deerfield, IL) cou-
pled with packing can be utilized for hemostasis. Not uncom-
monly, bone bleeding on the lateral vertebral body wall occurs
and this can be stopped with application of bone wax. Lateral
dissection is carried anteriorly until one is ventral to the verte-
bral body. One typically encounters some additional resistance
to lateral dissection at the level of the disc spaces, but this is
always overcome with a careful and persistent technique.
Although complete exposure of the discs above and below the
PSO is not advised, some minimal exposure is often helpful as
an additional visual orientation cue prior to resecting a wedge
out of the vertebral body. It is important to note that in signifi-
cant coronal deformities, the majority of the vertebral body

LWBK836_Ch95_p987-998.indd 988 8/26/11 3:06:20 PM

 Chapter 95 Pedicle Subtraction Procedures for Complex Spinal Deformity 989

presents itself on the convexity of the curve. This has implica-

tions during both lateral wall dissection as well as resection.
Cases in which a posterolateral fusion mass exists, such as
correction of flatback deformity following a posterior fusion
with Harrington distraction instrumentation, additional resec-
tion is required to gain access to the lateral vertebral body wall.
Moreover, as it is optimal to have posterolateral bone-on-bone
apposition when the PSO is closed for fusion purposes, too
much resection of this lateral fusion mass is not advised. When
the PSO is closed, one of the goals is apposition of lateral fusion
mass bone bilaterally in order to maximize the chance for
fusion across the osteotomy. If one is shooting for a 35 sagittal
correction at the PSO, then approximately 3.5 cm of fusion
mass should be resected. Fusion mass removal may also be
asymmetric if coronal correction is desired. Once parameters
for the extent of lateral fusion mass are determined, the bone
is removed in piecemeal fashion using a combination of osteot-
omes, rongeurs, and a high-speed drill. All bone removed
should be saved for later grafting. After lateral fusion mass
resection is carried out flush with the lateral wall of the pedicle
Figure 95.2. A curette is introduced into the pedicle, and the
at the level of the PSO, the lateral wall of the vertebral body is
vertebral body is decancellated. (Reprinted with permission from
then dissected in the manner previously described. Bridwell KH, Lewis SJ, Rinella A, Lenke LG, Baldus C, Blanke K.
Once lateral dissection is carried anterior to the vertebral Pedicle subtraction osteotomy for the treatment of fixed sagittal
body, malleable retractors or specialized lateral vertebral body imbalance. Surgical technique. J Bone Joint Surg Am 2004;86:4449.)
wall retractors (PSO tool set, Medtronic Spinal and Biologics,
Memphis, TN) that slide in a plane lateral and then anterior to
the spinal column are placed in order to maintain exposure be done with curettes. Also being mindful of the geometry of
during vertebral bodywork. These lateral retractors are versa- the resection, cancellous bone is removed from the vertebral
tile and can actually be used in part as dissectors once an initial body flush with the anterior vertebral cortex and posterior ver-
plane is developed with the Penfield instruments. It is impor- tebral body wall. In order to ensure that the closure is not held
tant to note that with lateral retraction, additional tension is up, a high-speed drill is used to remove anterior cortical bone
placed on the nerve root at the level of the PSO. One must be to expose just the lateral extent of the anterior longitudinal
very careful so as to avoid placing undue tension on this root if ligament. A temporary rod is placed on the ipsilateral side, and
at all possible. As such, we minimize the amount of time this the same steps are carried out contralaterally after the contral-
lateral vertebral body wall retractor is in place and only use it ateral temporary rod is removed.
when absolutely necessary for visualization. After the lateral
body wall is dissected free bilaterally, sponges are packed in this
space in order to keep it distended while attention is turned to
further pedicle resection and vertebral body decancellation.
Using the initially placed pedicle preparatory hole as a
guide, a curette is introduced into the pedicle and then verte-
bral body (Fig. 95.2). Cancellous bone, which may be minimal
on the concavity of a severe scoliotic deformity, is removed
from the pedicle and vertebral body. The pedicle is resected
flush with the posterior vertebral body wall using a combina-
tion of Leksell and Kerisson rongeurs as well as a high-speed
drill (Fig. 95.3). One then expands the resection of the pedicle
to ensure that the exiting root at the level of the PSO is com-
pletely free. At this point, a unilateral temporary rod is placed
and vertebral body resection is begun on the contralateral side.
Obviously, the temporary rod can be switched from side to side
in order to facilitate resection bilaterally.
With a contralateral temporary rod in place, the lateral ver-
tebral body wall retractor is reintroduced and the temporarily
packed sponges are removed. With the assistant protecting and
gently retracting the thecal sac medially, an osteotome is used
to perform lateral vertebral body wall cuts in a wedge-shaped Figure 95.3. The pedicles are resected flush with the posterior
fashion (Fig. 95.4). These cuts may also be performed with a vertebral body using a combination of rongeurs and a high-speed
high-speed drill. It is important to make these lateral cuts in the drill. (Reprinted with permission from Bridwell KH, Lewis SJ, Rinella
vertebral body as wedge shaped as possible as the cortical lat- A, Lenke LG, Baldus C, Blanke K. Pedicle subtraction osteotomy for
eral walls will define the geometry of PSO closure. With the the treatment of fixed sagittal imbalance. Surgical technique. J Bone
lateral wall cut, central vertebral body cancellous resection can Joint Surg Am 2004;86:4449.)

LWBK836_Ch95_p987-998.indd 989 8/26/11 3:06:23 PM

 990 Section VIII Adult Spinal Deformity
Figure 95.4. While gently retracting the thecal sac medially, an
osteotome is used to perform lateral vertebral body wall cuts in a
wedge-shaped fashion. (Reprinted with permission from Bridwell KH,
Lewis SJ, Rinella A, Lenke LG, Baldus C, Blanke K. Pedicle subtrac-
tion osteotomy for the treatment of fixed sagittal imbalance. Surgical
technique. J Bone Joint Surg Am 2004;86:4449.)
The last part of the vertebral resection is the posterior verte-
bral body wall or floor of the spinal canal (Fig. 95.5). It is essen-
tial in this step to control epidural bleeding with the judicious
use of bipolar cauterization, topical hemostatic agents such
as FloSeal (Baxter U.S., Deerfield, IL), Gelfoam (Pharmacia,
Kalamazoo, MI), and cottonoids sponges. The thecal sac
must be circumferentially freed and then separated from the
Figure 95.5. The posterior vertebral body wall is impacted into
the vertebral body defect created by the osteotomy. (Reprinted with
permission from Bridwell KH, Lewis SJ, Rinella A, Lenke LG, Baldus
C, Blanke K. Pedicle subtraction osteotomy for the treatment of fixed
sagittal imbalance. Surgical technique. J Bone Joint Surg Am
2004;86:4449.)
LWBK836_Ch95_p987-998.indd 990
epidural venous complex as well as the posterior longitudinal
ligament (PLL). Developing a plane between the PLL and ven-
tral thecal sac is not often difficult and best accomplished with
a Woodson elevator. When the thecal sac is adherent to the
PLL, it often occurs at the disc spaces where there tends to be
osteophytic lipping. This is especially true in cases for which
prior anterior discectomy and fusion have been performed.
This posterior vertebral wall must be removed in its entirety
with reverse-angled curettes, Woodson elevators, or a special-
ized posterior wall impactor (PSO tool set, Medtronic Spinal
and Biologics, Memphis, TN). After a ventral epidural tissue
plane is well established, we prefer to remove the posterior ver-
tebral body wall with the specialized impactor, which is utilized
to impale the posterior wall into the ventral defect that has
been created. It is imperative that the ventral spinal cord is
completely free of any bony prominences to avoid impinge-
ment prior to PSO closure.
With the PSO completed, closure of the osteotomy is per-
formed (Fig. 95.6). This can be carried out by a variety of
maneuvers starting with release of the set screws holding bilat-
eral temporary rods in place and manual reduction. Other
methods of PSO closure are described in Table 95.2. If the PSO
is performed correctly, the spine will be unstable enough that
the osteotomy is closed very easily with limited force. Gentle
compression across screws above and below the PSO is often all
that is required for osteotomy closure. In patients with poor
bone stock, a central laminar hookrod construct can be used
for osteotomy closure in order to avoid stressing permanent
fixation points. This closure mechanism is particularly useful in
cases of a prior posterior fusion mass. Alternatively, a construct-
to-construct closure can be performed in which two rods locked
Figure 95.6. Closure of the pedicle subtraction osteotomy is the
last step performed. (Reprinted with permission from Bridwell KH,
Lewis SJ, Rinella A, Lenke LG, Baldus C, Blanke K. Pedicle
subtraction osteotomy for the treatment of fixed sagittal imbalance.
Surgical technique. J Bone Joint Surg Am 2004;86:4449.)
8/26/11 3:06:25 PM
 Chapter 95 Pedicle Subtraction Procedures for Complex Spinal Deformity
TABLE 95.2 Methods of Closing a PSO
Manual reduction
Cantilevering a lordotically contoured rod across the PSO
Hyperextension of the chest and lower extremities
Compression across a single set of screws above and below the
PSO
Construct-to-construct closure using multiple screws and a
domino connector
Compression across a central hookrod system
PSO, pedicle subtraction osteotomy.
to several screws above and below the PSO are compressed via
a domino connector. This closure technique allows force to be
loaded over several fixation points thereby minimizing the
stress on any one bonescrew interface. During and after PSO
closure, the thecal sac and nerve roots at the level of the osteot-
omy are rigorously evaluated with nerve hooks and Woodson
elevators for any undue compression. If necessary, additional
laminectomy above and below the osteotomy can be per-
formed.
SAGITTAL/CORONAL CORRECTION
Bridwell et al2 reported a mean 36 focal sagittal correction at
the PSO site in their 33 studied patients. Their study group also
witnessed a statistically significant increase in lumbar lordosis
and thoracic kyphosis, as well as a marked improvement in
global sagittal balance (Figs. 95.7 to 95.9). Of note, a profound
overall improvement in validated clinical outcome measures
(Scoliosis Research Society (SRS)/Oswestry) was observed that
mirrored the favorable radiographic outcome. Using a similar
PSO technique, Yang et al20 reported a mean focal osteotomy
correction of 28 in concert with statistically significant improve-
ments in both regional and global sagittal balance. Several
other authors report sagittal correction results that resemble
these findings.9,12,19 Using a transdiscal PSO approach that
more closely resembles a VCR in terms of correction mechan-
ics, Boachie-Adjei et al1 were able to achieve a mean correction
of lumbar lordosis by 40 with each osteotomy.
Little is described about the impact of PSO on coronal cor-
rection largely because of its relatively limited role in patient
outcome as compared to sagittal correction. Moreover, most
PSOs are performed with the sole purpose of treating sagittal
imbalance. This aside, a significant coronal correction can be
achieved if so desired with a PSO. Performing an asymmetric
PSO in which a larger wedge is resected on the convexity of the
kyphoscoliotic deformity than the concavity will result in focal
coronal correction. To facilitate coronal correction on the con-
vexity, one can close the osteotomy by compressing along the
screws on the convexity of the curve. Alternatively, compression
across an asymmetrically placed hookrod construct can dial in
a significant coronal correction. If a hookrod construct is used
for PSO closure, we advocate the use of a unilateral concave
tracking rod so as to avoid subluxation across the osteotomy.
After preferential closure of a PSO along the convexity, addi-
tional coronal rebalancing can be introduced with appropriate
in situ rod contouring.
LWBK836_Ch95_p987-998.indd 991
991
PSEUDARTHROSIS
Pseudarthrosis in patients who undergo a PSO for deformity
correction is in accord with rates of pseudarthrosis found in the
general adult spinal deformity literature. In the analysis per-
formed by Bridwell et al,2 there were 8 cases of pseudarthroses
in 33 patients who underwent PSO. Importantly, this study pre-
dates the use of biologic agents in adult deformity that has
been associated with higher fusion rates. Of these pseudart-
hroses, six were in the thoracic spine proximal to the PSO, one
at the lumbosacral junction, and one in the region of the
osteotomy in a patient with a prior laminectomy at this site.
Interestingly, in the patients with prior surgery and a preexist-
ing posterolateral fusion mass, there were no pseudarthroses at
the PSO site. These pseudarthrosis rates are shared by other
surgeons reporting their results of PSO for the treatment of
fixed sagittal imbalance.
In order to avoid pseudarthrosis in a primary case in which
a PSO is performed, interbody arthrodesis above and below the
osteotomy can be carried out. Depending on the anatomy of
the deformity, cephalad disc resection during the PSO may be
performed, thereby converting the osteotomy to a so-called,
extended PSO. Similarly, performing transforaminal lumbar
interbody fusions (TLIFs) with structural cages and bone graft
above and below the PSO is rather easily performed with the
generous access already obtained for completion of the PSO.
Alternatively, if one prefers to fill-in caudal discs using an
anterior lumbar interbody fusion (ALIF) approach in a second
stage, anterior interbody arthrodesis above and below the PSO
can be performed at the same setting. Through a minimally
invasive incision, structural interbody cages can also be placed
above and below the osteotomy through a single transpsoas
approach. The potential neurological morbidity in terms of
upper lumbar neurapraxia following the transpsoas approach
for interbody fusion has limited our uniform acceptance of this
technique as a viable option.
COMPLICATIONS OF LUMBAR PSO
A variety of complications can be associated with a PSO
(Table 95.3). General medical complications following surger-
ies that involve a lumbar PSO for sagittal and/or coronal
realignment are similar to those associated with other opera-
tions for patients with adult spinal deformity.7 A minor ileus
appears to be quite common after surgery in patients who have
undergone a PSO and might be due to the focal correction
afforded by this osteotomy. Other more significant early and
late complications of surgery involving a lumbar PSO are out-
lined by Bridwell et al2 and include respiratory distress, myocar-
dial infarction, deep venous thrombosis, and wound infection.
Surgical complications during PSO surgery are important to
recognize and correct in order to prevent neurologic injury.
Our long-term neurologic results, as reported by Buchowski
et al4 have shown us the importance of performing a judicious
central laminectomy to allow dural redundancy during PSO
closure. Prior to routinely doing this, we had several patients in
whom a neurologic deficit was picked up either during a post-
closure wake-up test, immediately after surgery, or in a delayed
fashion (1 week after surgery). Deficits ranged from neural
root palsies resulting in quadriceps or anterior tibialis weakness
8/26/11 3:06:27 PM
 992 Section VIII Adult Spinal Deformity

A B

C D

Figure 95.7. Case example. A 47-year-old woman who was fused in kyphosis from T12 to the sacrum as a
teenager for the treatment of spondyloptosis. Her instrumentation was removed and a solid fusion was
confirmed intraoperatively. Currently, she presented with severe low back pain and difficulty standing in an
erect posture. Her standing anteroposterior (AP) long cassette radiograph (A) reveals some coronal imbal-
ance with trunk shift to the left. Lateral films in both compensated (B) and uncompensated (C) posture show
lumbar hypolordosis and profound global sagittal imbalance. A sagittal magnetic resonance imaging (D) does
not reveal any central, lateral recess, or foraminal stenosis above L5. We reinstrumented her from T12 to the
sacrum/ilium and performed a pedicle subtraction osteotomy at L3. (continued)

LWBK836_Ch95_p987-998.indd 992 8/26/11 3:06:27 PM

 Chapter 95 Pedicle Subtraction Procedures for Complex Spinal Deformity 993

E F

G H

Figure 95.7. (Continued) Her AP (E) and lateral (F) postoperative films at 2-year follow-up reveal improve-
ment in her coronal balance and restoration of global sagittal balance. Clinical photographs also show a
marked improvement (GJ). Her Scoliosis Research Society Outcome Score improved from 39 to 80, and her
Oswestry Disability Index decreased from 42 to 8. (continued)

LWBK836_Ch95_p987-998.indd 993 8/26/11 3:06:28 PM

 994 Section VIII Adult Spinal Deformity
I J
Figure 95.7. (Continued)
to bladder dysfunction. In all cases, further central decompres-
sion reversed the impairment.
In addition to a thorough central decompression, the impor-
tance of performing a rigorous decompression of the nerve
root exiting under the pedicle at the level of the PSO cannot be
overstated. This root is particularly prone to compression after
osteotomy closure if the inferior ledge of the pedicle is not
resected in its entirety. In order to avoid a compressive postop-
erative radiculopathy, this ledge must be completely removed
and ideally the bone of the posterior vertebral body wall lying
ventral to the root also be resected if there is any suggestion of
compression after the osteotomy is closed.
In the final step of performing a PSO, namely impaction of
the posterior vertebral body wall, a ventral durotomy may occur.
As stated previously, this is most common in the setting of prior
anterior surgery at the level of the disc spaces. In cases where
surgery has not been previously performed or only prior poste-
rior surgery, a plane in between the ventral dura and PLL is
almost always readily developed with a Woodson elevator and
durotomy avoided. Should a ventral durotomy with cerebrospi-
nal fluid leakage occur, however, applying a circumferential
sling of dural substitute appears to be very effective in con-
junction with closure of the osteotomy.
One important structural issue worth noting is the potential
for subluxation across the PSO during osteotomy closure. This
appears to be more prone to occur when the PSO is performed
through a fusion mass. Because the hips are extended on a
Jackson table, the distal limb of the PSO tends to sublux anteri-
orly with respect to the proximal limb. This subluxation can
be overcome or avoided by applying cantilever forces from
LWBK836_Ch95_p987-998.indd 994
Complications of Lumbar
TABLE 95.3 Pedicle Subtraction
Osteotomy
Substantial intraoperative blood loss
Postoperative medical complications (cardiac, pulmonary,
renal, etc.)
Neurologic injury (temporary vs. permanent)
Durotomy (dorsal vs. ventral)
Segmental subluxation during osteotomy closure
Pseudarthrosis in the region of the osteotomy
Adjacent segment degeneration/junctional deformity
Suboptimal global sagittal or coronal balance
Wound infection
proximal to distal during osteotomy closure. An additional
helpful tool to treat this problem should it occur is the use of
reduction screws above and below the osteotomy, particularly
below the PSO.
THORACIC PSO
In a manner analogous to the surgical technique for lumbar
PSO, a PSO can be safely performed in the thoracic spine.
Minor procedural variations exist between a lumbar and tho-
racic PSO, including the need for bilateral rib head resection
in the thoracic spine and the fact that a thoracic PSO is per-
formed at cord level. In their analysis of 25 thoracic PSOs for
the treatment of fixed thoracic kyphosis, OShaughnessy et
al13 found a mean correction of 16.3  9.6. Their data
showed that the correction from a thoracic PSO was depen-
dent on the level at which the osteotomy was performed; the
greatest correction (23.9  4.1) was afforded in the distal
thoracic spine as these levels most closely resemble the lum-
bar spine in terms of size and pedicle morphology. Limita-
tions of thoracic PSO in terms of corrective potential are
related to the comparatively shorter thoracic vertebral bodies
that possess a triangulated morphology in the axial plane as
well as the relative sagittal height of the pedicle versus verte-
bral body. In another analysis, OShaughnessy et al14 deter-
mined that a more reliably robust correction in the thoracic
spine was achieved with VCR, and as such, this osteotomy may
be a more viable alternative to PSO for fixed thoracic kyphosis
correction. A general framework for osteotomy decision mak-
ing is shown in Figure 95.10.
CONCLUSIONS
Lumbar PSO is a valuable surgical technique to achieve poste-
rior-only correction of fixed sagittal imbalance. Performed
safely, PSO offers the ability to restore normal lumbar lordosis
with limited neurologic risk. Perioperative complications,
which may be significant, are synonymous with those reported
for the surgical treatment of adult spinal deformity. In concert
with global sagittal reorientation, PSO is associated with excel-
lent overall clinical outcomes.
8/26/11 3:06:29 PM
 Chapter 95 Pedicle Subtraction Procedures for Complex Spinal Deformity 995

A B

E F

C D G H

Figure 95.8. Case example. A 43-year-old woman with idiopathic scoliosis had a total of eight prior
surgeries at the time of presentation to us. Her surgical treatment included a posterior spinal fusion down to
L3 with Harrington instrumentation. She subsequently underwent a pedicle subtraction osteotomy (PSO) at
L4 and was extended down to the sacrum/ilium. She had bilateral iliac crest harvest. At the time of our
evaluation, she had a pseudarthrosis at L5-S1 and painful fixed sagittal/coronal imbalance. Her standing
anteroposterior (AP) (A) and lateral (B) long cassette radiographs reveal both coronal and sagittal imbalance
with trunk shift to the right. We anchored into her fusion mass with hooks, extended her instrumentation
down to the ilium, and performed an asymmetric PSO at L2. Her AP (C) and lateral (D) postoperative films
at 4-year follow-up reveal a significant two-plane correction with improvement in her coronal balance and
restoration of global sagittal balance. Clinical photographs also show a marked improvement (EH).

LWBK836_Ch95_p987-998.indd 995 8/26/11 3:06:31 PM

 996 Section VIII Adult Spinal Deformity

A B

C D

Figure 95.9. Case example. A 58-year-old woman with idiopathic scoliosis many years status post a Har-
rington rodbased posterior spinal fusion down to L5. She presented with severe low back and fixed positive
sagittal imbalance. Her standing anteroposterior (AP) (A) and lateral (B) long cassette radiographs reveal sig-
nificant global sagittal imbalance. We anchored into her fusion mass with hooks, extended her instrumenta-
tion down to the sacrum/ilium, and performed a pedicle subtraction osteotomy at L2. Her AP (C) and lateral
(D) postoperative films at 4-year follow-up reveal a significant sagittal plane correction. (continued)

LWBK836_Ch95_p987-998.indd 996 8/26/11 3:06:34 PM

 Chapter 95 Pedicle Subtraction Procedures for Complex Spinal Deformity 997

E F

G H

Figure 95.9. (Continued) Clinical photographs also show a marked improvement (EH).

LWBK836_Ch95_p987-998.indd 997 8/26/11 3:06:35 PM

 998 Section VIII Adult Spinal Deformity

Algorithm for Osteotomy Type Based on the Character

of the Sagittal Deformity

Type I Type II
Deformity Deformity

Smooth Sharp Angular Smooth Sharp Angular

Kyphosis Kyphosis Kyphosis Kyphosis

Thoracic Lumbar Thoracic Lumbar Minor Major Minor Major

Imbalance Imbalance Imbalance Imbalance

SPOs VCR PSO

Thoracic Lumbar Thoracic Lumbar Thoracic Lumbar Thoracic Lumbar

SPOs SPOs PSO VCR PSO VCR PSO

Figure 95.10. Decision analysis in osteotomy planning. PSO, pedicle subtraction osteotomy; SPO, Smith-
Petersen osteotomy; VCR, vertebral column resection.

REFERENCES 11. Leong JCY, Ma A, Yau AC. Spinal osteotomy for fixed flexion deformity. Orthop Trans
1978;2:271.
12. Murrey DB, Brigham CD, Klebzak GM, Finger F, Chewning SJ. Transpedicular decompres-
1. Boachie-Adjei O, Ferguson JA, Pigeon RG, Peskin MR. Transpedicular lumbar wedge resec-
sion and pedicle subtraction osteotomy (eggshell procedure): a retrospective review of 59
tion osteotomy for fixed sagittal imbalance: surgical technique and early results. Spine
patients. Spine 2002;27:23382345.
2006;31:485492.
13. OShaughnessy BA, Kuklo TR, Hsieh PC, Yang BP, Koski TR, Ondra SL. Thoracic pedicle
2. Bridwell KH, Lewis SJ, Edwards C, et al. Complications and outcomes of pedicle subtrac-
subtraction osteotomy for fixed sagittal spinal deformity. Spine 2009;34:28932899.
tion osteotomies for fixed sagittal imbalance. Spine 2003;28:20932101.
14. OShaughnessy BA, Kuklo TR, Hsieh PC, et al. A comparison between thoracic pedicle
3. Bridwell KH, Lewis SJ, Rinella A, Lenke LG, Baldus C, Blanke K. Pedicle subtraction osteot-
subtraction osteotomy and posterior vertebral column resection for the treatment of fixed
omy for the treatment of fixed sagittal imbalance. Surgical technique. J Bone Joint Surg
sagittal spinal deformity. [abstract]. 14th Annual International Meeting of Advanced Spine
Am 2004;86:4449.
Techniques (IMAST), Bahamas, July, 2007.
4. Buchowski JM, Bridwell KH, Lenke LG, et al. Neurologic complications of lumbar pedicle
15. OShaughnessy BA, Ondra SL. Measuring, preserving, and restoring sagittal spinal bal-
subtraction osteotomy: a 10-year assessment. Spine 2007;32:22452252.
ance. Neurosurg Clin N Am 2007;18:347356.
5. Cho KJ, Bridwell KH, Lenke LG, Berra A, Baldus C. Comparison of Smith-Petersen versus
16. Potter BK, Lenke LG, Kuklo TR. Prevention and management of iatrogenic flatback defor-
pedicle subtraction osteotomy for the correction of fixed sagittal imbalance. Spine
mity. J Bone Joint Surg Am 2004;86:17931808.
2005;30:20302037.
17. Shamji MF, Isaacs RE. Anterior-only approaches to scoliosis. Neurosurgery 2008;63
6. DAliberti G, Talamonti G, Villa F, et al. Anterior approach to thoracic and lumbar spine
(Suppl 3):139148.
lesions: results in 145 consecutive cases. J Neurosurg Spine 2008;9:466482.
18. Thomasen E. Vertebral osteotomy for correction of kyphosis in ankylosing spondylitis. Clin
7. Daubs MD, Lenke LG, Cheh G, Stobbs G, Bridwell KH. Adult spinal deformity surgery:
Orthop 1985;194:142152.
complications and outcomes in patients over age 60. Spine 2007;32:22382244.
19. Wu SS, Hwa SY, Lin LC, et al. Management of rigid post-traumatic kyphosis. Spine
8. Heinig CF. Eggshell procedure. In Luque ER (ed). Segmental spinal instrumentation.
1996;21:22602267.
Thorofare, NJ: Slack, 1984;221230.
20. Yang BP, Ondra SL, Chen LA, Jung HS, Koski TR, Salehi SA. Clinical and radiographic
9. Kim KT, Suk KS, Cho YJ, Hong GP, Park BJ. Clinical outcome results of pedicle subtraction
outcomes of thoracic and lumbar pedicle subtraction osteotomy for fixed sagittal imbal-
osteotomy in ankylosing spondylitis with kyphotic deformity. Spine 2002;27:612618.
ance. J Neurosurg Spine 2006;5:917.
10. Kim YJ, Bridwell KH, Lenke LG, Cheh G, Baldus C. Results of lumbar pedicle subtraction
osteotomies for fixed sagittal imbalance: a minimum 5-year follow-up study. Spine
2007;32:21892197.

LWBK836_Ch95_p987-998.indd 998 8/26/11 3:06:38 PM