1 Introduction top
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The aims of surgery are to:
- improve the spinal curve
- improve the three dimensional alignment of the spine
- prevent progression of the curve in the future
- improve cosmesis
- reduce pain
- optimize pulmonary function
- maintain neurological integrity
This is achieved by correction of the deformity and creation of a solid arthrodesis of the deformed part of the spine.
For this procedure we will assume a left PTC, right thoracic and a left lumbar curve.
Details on selection of fusion levels can be found here.
2 Approach and preparation top
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The procedure is performed through a posterior approach with the patient in the prone position. The lengths of the incision will depend on the levels being fused.
3 Pedicle screw insertion top
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Pedicle screws can be inserted into every second or into every level depending on surgeon's preference.
In the case of very stiff curves, screws may be inserted into every level.
Reduction screws are preferred for the caudal three levels.
4 Release top
Indications for release
Depending on flexibility findings, the release can be carried out only at the apex of the curve, which is usually the stiffest, or the whole length of the instrumented spine.
A release is generally performed if the spine cannot easily align to the rod during surgery. This can be predicted preoperatively based on the bending X-ray. For stiff curves, fulcrum bending X-ray and the traction X-ray under general anaesthesia is the method of choice for determining flexibility.
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Release
A soft tissue release can be performed by removal of the interspinous ligaments along with the midline ligamentum flavum of the apical regions of the deformity. If additional release is desired, then formal Posterior Column Osteotomy (PCO) can be performed at the same levels. PCO is also called SPO (Smith-Petersen osteotomy) or Ponte osteotomy. The shaded area to the left outlines the bony resection performed during a PCO.
All posterior releases begin by resecting the inferior aspect of the spinous process, followed by removal of the interspinous ligament utilizing a standard rongeur.
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Removal of the 3-5 mm of the inferior aspect of the inferior facet joint is performed at each level of the planned fusion using an osteotome.
The ligamentum flavum is removed with a Kerrison rongeur beginning in the midline and exiting lateral until abutting against the medial aspect of the superior facet. It is important not to penetrate deeply against the dura.
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Care should be taken not to tear the dura particularly on the concavity of the curve where the neuro tissues preferentially lie.
A Kerrison rongeur is utilized to remove the most cephalad portion of the superior articular facet exiting out lateral into the neuroforamen. This completes the PCO and is usually repeated at other levels.
Epidural bleeding within the neuroforamen is controlled with hemostatic agents and cottonoid packing.
5 Facet joint fusion top
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In cases where a PCO has been performed, the facet joint is already removed and this step ("Facet joint fusion") should be omitted.
The inferior articular facet is removed with a osteotome exposing the articular cartilage of the superior articular facet.
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Remove the articular cartilage from the superior articular facet using a gouge or a curette.
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Insert pieces of bone graft (autograft, allograft, or bone substitute) into the decorticated facet joint for arthrodesis.
These steps are repeated for all the levels on both sides.
6 Correction of the deformity top
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Left rod
The left rod is bent to the appropriate thoracic kyphosis and lumbar lordosis corresponding to the levels to be fused.
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The rod is rotated 90° degrees, into the appropriate sagittal alignment, engaged, and locked to the 1 or 2 most caudal screws to prevent the rod from rotating back. The other screw heads are unlocked.
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At this point compression is applied at the cranial three levels along the convexity of the proximal thoracic curve (PTC) correcting the proximal thoracic curve.
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Derotation of the spine
Vertebral screw derotation extenders are applied to the screw heads along the apex of the deformity on the concavity and the convexity of the main thoracic curve as well as the thoracolumbar curve.
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An apical derotational maneuver is then performed on the thoracic curve to simultaneously translate the apical vertebrae dorsally and medially to meet the kyphotically contoured concave rod. The screws are then sequentially locked to this rod from the ends to the apex.
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Secondary, an apical derotation maneuver is performed in the lumbar curve to simultaneously translate the lumbar apex medial and ventral to create increased lumbar lordosis while correcting the scoliosis.
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Concave distraction
Holding the spine in a derotated position, distraction is performed starting at the apex pushing caudal against the lower screws while pushing cranial against the upper screws. After the distraction is performed. Each set screw is locked down to hold the correction.
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Compression on convex side
The lumbar convex screws are then compressed towards the apical anchor to horizontalize each vertebra and then locked in position.
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Coronal benders applied for fine tuning the correction. Care is taken to apply only minimal stress in order to prevent bone-screw interface failure.
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Right rod
The right rod is bent to the appropriate thoracic kyphosis and lumbar lordosis corresponding to the levels to be fused.
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The rod is placed into the cranial thoracic screws on the right side and the set screws are applied loosely.
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The distal end of the rod is then levered down using a rod holder while sequentially being attached to the distal screws.
This cantilever maneuver helps reduce the apical thoracic convex rotational deformity.
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This maneuver will push the apical rib hump anteriorly, thereby achieving derotation of the apical segments.
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Compression on convex side
After locking the apical screw to the rod the convex main thoracic screws are compressed towards the apical anchor to horizontalize each vertebra, and then locked in position.
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Concave distraction is applied towards the locked lumbar apical anchor on the right sided rod.
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Compression (1) or distraction (2) is used at the cranial 2-3 levels in order to fine tune shoulder balance, and at the caudal 2-3 levels in order to optimize LIV position.
7 Spinal fusion top
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Decortication
The laminae and the transverse processes are decorticated with an osteotome.
Care should be taken to always point the osteotome away from the spinal canal.
Alternatively, the decortication may be performed with a powered burr.
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Bone grafting
Bone graft (allograft, autograft, or bone substitutes) is copiously placed over the entire decorticated area.
8 Transverse rod connectors (if desired) top
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Transverse connectors are optional in this technique based on overall construct stability.
9 Intraoperative imaging top
At some point prior to wound closure intraoperative imaging should check:
- Fusion levels
- Screw position
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Overall coronal and sagittal correction and alignment