CHAPTER
Frank L. Acosta Jr
92
Spinal Deformity in the Older
Patient With Kyphosis
KYPHOTIC SPINAL DEFORMITY AND
SAGITTAL IMBALANCE
The spinal column is globally kyphotic at birth (Fig. 92.1).
Secondary lordotic curvatures of the cervical and lumbar
spine first appear with the onset of crawling and walking,
respectively. The normal thoracic spine remains in kyphosis.
In the physiologic upright posture, these sagittal curves are
proportional to each other and the pelvis angle. Together,
they act to balance the spine such that the head and trunk are
situated directly over the pelvis to allow for balanced bipedal
locomotion.12
Spinal sagittal balance is the alignment of the C7 vertebral
body with the posterior superior aspect of S1 (plumb line) on
an upright standing 36-in. plain radiograph (Fig. 92.2A). A bal-
anced spine situates C7 within plus or minus 2 to 4 cm from the
sacral promontory. Sagittal imbalance occurs when the rela-
tionship of C7 to the posterior superior aspect of S1 falls out-
side of this value. Positive sagittal balance occurs when the C7
plumb line falls more than 2 to 4 cm in front of the sacrum
(Fig. 92.2B). Negative sagittal balance occurs when the C7
plumb line falls behind the sacrum.12 The most important goal
of adult deformity correction is to achieve anatomic sagittal
alignment postoperatively.6,7 Over time, it has become increas-
ingly clear that other important factors, such as hip orientation
relative to the sacrum, play a pivotal role in the over all process
of sagittal alignment. In this chapter, we will focus on the more
common issues of spinal balance. It is recognized that as more
information about other global contributors to sagittal align-
ment become better understood, our knowledge and sophisti-
cation regarding this critical issue will continue to improve
patient management.
TREATMENT OF SAGITTAL IMBALANCE
NONOPERATIVE MANAGEMENT
Although nonoperative treatment strategies will not prevent
progression of kyphosis and positive sagittal balance in the
older adult patient, they may provide symptomatic relief.
Nonsteroidal anti-inflammatory drugs and physical therapy
962
LWBK836_Ch92_p962-969.indd 962
Tyler Koski
Stephen L. Ondra
consisting of exercise and activity modificationsare the main-
stays of nonsurgical management. Low-impact aerobics, cycling,
and swimming are particularly useful in older adults with pain-
ful spinal deformities and may also help to prevent osteoporo-
sis, a condition that can worsen an existing kyphosis.10 The
older adult population, which is at risk for osteoporosis, should
be screened with bone densitometry and started on pharmaco-
logic treatment when osteopenia is documented.10 Although
useful in the pediatric and adolescent deformity population,
bracing has not proven to be an effective treatment for older
adults with kyphosis and sagittal imbalance. Although such
strategies may help in the short run, the prolonged use of
external support may ultimately add to atrophy of the muscular
soft tissue envelop. This may well exacerbate sagittal alignment
problems and patient dysfunction.
Currently, there is little evidence regarding what nonsurgi-
cal treatments are the most effective for patients. As such,
efforts on muscle strengthening, bone health, and symptomatic
treatment are recommended.
SURGICAL TREATMENT AND TECHNIQUES
Indications
Although the timing and the type of surgical intervention must
be tailored to each individual patient, there are four general
indications for surgical intervention in the older deformity
patient with kyphosis: unrelieved pain, progressive deformity
with functional disability, neurological deficit, and cosmesis.
The most important goal of adult deformity correction is to
achieve pain relief and functional improvement by obtaining
anatomic sagittal alignment.6,7 Other general principles in
adult deformity surgery include avoiding termination of con-
struct at the thoracolumbar junction or the apex of a coronal
curve or sagittal curve.
Postural correction under general anesthesia is the first
step in the surgical treatment of a structural spinal deformity.
The patient shows more flexibility due to the elimination of
pain and increased muscle relaxation seen under anesthesia.
Once this has been optimized, there are two primary surgical
techniques for the correction of kyphosis and restoration of
lordosis: Smith-Petersen osteotomy (SPO) and three-column
8/26/11 10:02:01 PM

Figure 92.1. In utero, an ultrasound image of the spine. Note that
it is completely kyphotic.
bony resection. The latter can take the form of a partial
wedge-shaped vertebral resection that creates and anterior
anatomic pivot point. This is the pedicle subtraction osteot-
omy (PSO). The other three-column resection is a full spon-
dylectomy with a surgically placed device that serves as a pivot
Figure 92.2. Adult spine with neutral sagittal balance maintained
on the left image, despite degenerative disease. This is done through
compensation. On the right, the spine has not been able to maintain
normal sagittal balance. In this case, balance is pathologically positive.
LWBK836_Ch92_p962-969.indd 963
Chapter 92 Spinal Deformity in the Older Patient With Kyphosis 963
CD
CD
Adj
or PSPL
PLH
PLH
C
Opp
CD Opp PL
= = tan
PLH Adj
PSPL
= tan1
Figure 92.3. These diagrams demonstrate the method for calcula-
tion of needed sagittal correction. CD; PL; PLH; PSPL.
point. This is termed vertebral column resection (VCR). The
choice of surgical technique is dictated mainly by the degree
of correction needed, the characteristics of the spine, and the
location of the sagittal deformity being treated.
The first step is to assess how much correction is needed to
achieve balance from the standing neutral scoliosis radio-
graphs. Surgery simply cannot be adequately planned without
such radiographs to assess alignment and restoration goals.
The total degrees of correction can be calculated by measuring
the distance from C7 to the vertical plumb line passing through
the posteriorsuperior end plate of S1. This distance, the dis-
tance of the required correction, can be divided by the distance
from the planned osteotomy to C7 (Fig. 92.3). This establishes
the tangent of the angle needed for correction. The inverse of
this gives the number of degrees of correction needed. Today,
most PACS machines will calculate this easily for the surgeon.
Once the total amount of correction is known, the surgeon
must establish how much postural correction can be achieved.
This can be subtracted from the total needed degrees of correc-
tion to establish the surgical correction needed. Once this is
known, the surgeon can reliably predict the number and type
of osteotomies needed.
Careful planning is the key to accurate surgical correction
and restoration of sagittal alignment. Obviously, this analysis
is well worth the surgeons time prior to surgery and will
greatly increase the chances for a surgical success. In the
remainder of this chapter, we will discuss the surgical tech-
niques for changing sagittal alignment. Each osteotomy has
advantages, risks, and limitations. As such, the choice on the
type of osteotomy is dependant on situation and goal. Each is
a tool for a specific situation and surgical need. This chapters
goal is to help surgeons pick the right tool to achieve their
need.
8/26/11 10:02:01 PM
 964 Section VIII Adult Spinal Deformity
Characteristics of Smith-Petersen and Pedicle Subtraction
TABLE 92.1
Osteotomies
Smith-Petersen Osteotomy
Kyphosis type Long, smooth
Method of kyphosis Posterior column shortening,
correction anterior column elongation
Correction per osteotomy 10 to 15
Smith-Petersen Osteotomy (Table 92.1)
The surgical correction of kyphosis via multiple posterior
osteotomies through ankylosed facet joints was first described
by Smith-Petersen et al in 1945.13,15 This technique, as well as
various modifications of it,3,8,11,14 achieves segmental lordosis
through a shortening of the posterior spinal column. The
simultaneous anterior column lengthening occurs through the
posterior margin of the intervertebral disc. Therefore, larger
disc spaces allow an easier and more effective correction with
this technique. Correction is difficult in collapsed disc spaces
unless disc height can be restored by surgical means (Fig. 92.4).
In ankylosed segments, fracturing of the ankylosis and anterior
elongation is possible. This has added risk and may not be pos-
sible in the osteopenic spine. In view of this, the utility of this
technique depends on the presence of mobile and relatively
Figure 92.4. Patient with positive sagittal balance and correction
using postural means and Smith-Petersen osteotomies.
LWBK836_Ch92_p962-969.indd 964
Pedicle Subtraction Osteotomy
Sharp, angular
Posterior and middle column shortening
30 to 45
healthy disc spaces through the levels at which SPOs will be
performed. In such a situation, 7 to 10 of correction can be
expected per closed osteotomy. Typically, 1 of correction will
be achieved for each millimeter of posterior spinal closure.
The patient is positioned prone on a lordosing table such as
the Jackson table. Adequate chest bolstering and hip support is
necessary to maximize postural lumbar lordosis before begin-
ning surgery. We will typically obtain a radiograph to assess pos-
terior correction. Adjustments in the surgical plan to restore
spinal balance can then be determined. After exposure, three-
column pedicle screw fixation should be obtained above and
below the osteotomy site. The interspinous ligament is removed
with a Leksell rongeur; the osteotomy is begun in the interlami-
nar space at the base of the spinous process. By using a combina-
tion of a high-speed drill and Kerrison rongeurs, a V-shaped
area of bone is resected, extending laterally. The inferior facet
of the superior segment is removed to gain access to the supe-
rior facet of the caudal level. The caudal segment superior facet
should be completely removed to the level of the pedicle. This
will avoid it moving superior and anterior during osteotomy clo-
sure and potentially impacting on an exiting nerve rood. Only
enough upper level inferior facet should be moved to allow the
full and desired closure. In the end, the goal is closure of the
resection and not the creation of a bony defect (Fig. 92.5A). It is
important to avoid accidentally entering into the pedicle, which
can be difficult in cases of an existing fusion mass over the SPO
site. In such cases, it is helpful to identify the exiting nerve root
and follow it through the foramen with the drill and Kerrison
rongeurs. Once bony resection is complete, the ligamentum fla-
vum is removed. This will facilitate closure and avoid stenotic
buckling of the ligamentum. After completion of bony and liga-
mentous resection, rods are placed bilaterally and the osteot-
omy closed by the application of a combination of compressive
and cantilever forces (Fig. 92.5B). If needed, a temporary cen-
tral hook and rod can be placed to help in osteotomy closure
and avoid excessive pedicle screw compression, which could dis-
rupt the integrity of the bonemetal interface.
In general, SPOs are most useful for correcting a long,
smooth kyphosis versus a sharp, angular kyphosis. The latter is
better suited for correction with a PSO or VCR (Fig. 92.6). As
mentioned, 5 to 10 (mean of 7) of correction per segment is
possible with multiple SPOs. Some authors claim up to 15 of
correction, but we have found this an optimistic estimate.
Again, it is important to remember that 1 of correction is pos-
sible with each degree of actual closure and not resection.1,8,13
This technique is useful in both thoracic and lumbar spines.
Pedicle Subtraction Osteotomy (Table 92.1)
The PSO is a more powerful technique for correcting kyphosis.
It can reliably achieve between 25 and 35 of correction with a
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 Chapter 92 Spinal Deformity in the Older Patient With Kyphosis 965

A B

Figure 92.5. Left figure demonstrates the resection needed during the performance of a Smith-Petersen
osteotomy (SPO). Note the complete resection of the superior facet. The right figure demonstrates the SPO
closed. The goal is the closure of the osteotomy, not the creation of a defect.

single osteotomy (Table 92.2). Corrections of up to 45 are pos-

sible. The PSO is a true three-column resection but the ante-
rior bone edge is preserved as an anatomic pivot (Fig. 92.7).
This is one of the major surgical resection differences between
this technique and the VCR. The goal of the PSO is to remove
the posterior bony elements, bilateral pedicles, and a wedge-
shaped portion of the vertebral body. This is done with ron-
geurs, curettes, and drills. Bone is saved for later grafting. The
size of the wedge resection will determine the number of
degrees of correction when closure is achieved (Fig. 92.8). This

Technical Details of Surgical

TABLE 92.2
Osteotomies

Osteotomy Type Bony Resection Pivot

Smith-Petersen Posterior lamina, pars Posterior disc
interarticularis, margin
(inferior facet)
Pedicle Spinous process, Anterior vertebral
subtraction lamina, pars cortex
interarticularis,
transverse process,
pedicle, vertebral
body wedge
Vertebral column Spinous process, Anterior column
resection lamina, pars interbody graft
interarticularis,
Figure 92.6. This case has collapsed disc spaces at the desired transverse process,
level of Smith-Petersen osteotomy correction. Disc height has been pedicle, entire
restored through transforaminal lumbar interbody fusion allowing the vertebral body
needed angles of correction.

LWBK836_Ch92_p962-969.indd 965 8/26/11 10:02:02 PM

 966 Section VIII Adult Spinal Deformity
Figure 92.7. In the figure on the left,
the shaded area reflects the bony resection
for the pedicle subtraction osteotomy
(PSO). The figure on the right demon-
strates the angular correction achieved
with a PSO closure.
can be calculated and measured by templates or mathematical
calculations to improve the accuracy of the correction.
After exposure, three-column pedicle screw fixation is
obtained above and below the PSO level. Typically, at least two
screws per side (total four) should be placed above and below
the PSO site to have adequate control of this more unstable
osteotomy. The posterior elements are removed entirely, includ-
ing the superior and inferior articular processes and transverse
processes. We will often leave the lateral aspect of the trans-
verse process as a vascularized graft. An extended central
laminectomy is performed at levels above and below the osteot-
omy level to avoid canal stenosis after closure. After exposure
of the dura and bilateral nerve roots, the pedicles are isolated
and removed with a rongeur to save bone for later grafting.
The remaining pedicle is then drilled flush to the posterior ver-
tebral body wall. Next, a temporary rod is placed on the non-
working side and a wedge-shaped portion of the cancellous
vertebral body and lateral vertebral body wall is removed by
using an osteotome. This can then be smoothed and custom
cut to size by a combination of tools such as a high-speed drill
and Leksell and Kerrison rongeurs. The size of the wedge
should be determined preoperatively and is based on the
Figure 92.8. This is a demonstration of how the angular correc-
tion can be translated to the pedicle subtraction osteotomy to achieve
the desired correction. PL; PSPL.
LWBK836_Ch92_p962-969.indd 966
amount of correction desired. A larger wedge will result in
greater kyphosis correction. Care should be taken during expo-
sure of the lateral vertebral body wall in order to avoid injury to
the segmental vessels. This can be achieved by sweeping subpe-
riosteally from cephalad to caudal. If the segmental is injured,
bipolar coagulation can be attempted. However, packing and
rapid completion of the osteotomy may be necessary. Closure
will usually stop the bleeding. Although we have not had to do
more than is listed earlier, uncontrolled bleeding would be best
addressed by a lateral retroperitoneal approach, isolation of
the aorta, and segmental control at the branch exit. After wedge
resection of the vertebral body and lateral walls, the posterior
cortical vertebral body wall should be sufficiently thinned to
allow for fracture by using Woodson elevator, down-pushing
curettes, or specialized posterior vertebral body wall impactor.
Next, a second temporary rod is placed on the working side
and attention is turned to the contralateral side, where these
steps are repeated. Osteotomy closure is accomplished under
direct visualization through a series of compression maneuvers
(Fig. 92.9). All neural elements inspected, the wedge-shaped
osteotomy is closed by compressing the pedicle screws above
and below the osteotomy and allowing the spine to pivot on the
anterior vertebral body cortex. Before closure, it is important
to inspect the foramen and canal to ensure that there is no scar
tissue, ligament, or bone that could cause neural compression
with closure. If needed, a central laminectomy can be done to
ensure that there is no central stenosis. Once closed, the neural
elements are directly visualized and the new, expanded neural
foramen, which now contains two nerve roots. The foramen is
palpated with a nerve hook and Woodson elevator to ensure
adequate decompression. In cases where the osteotomy does
not hinge on the anterior column, such as when a discectomy is
performed at the cephalad end, an interbody cage can be posi-
tioned anteriorly to act as the pivot site during osteotomy clo-
sure. In these situations, the correction mechanics and
approach is much more analogous to a VCR.
When closing an osteotomy, care should be taken to ensure
that the spine does not sublux. When this occurs, the caudal
segment will usually fall anterior to the cephalad segment of
the spine. If this is a concern, spondylolisthesis reduction screws
can be used in the caudal segment to allow it to be pulled back
into position. Another concern is loosening of the bonemetal
interface in osteopenic spines. When this is a concern, a con-
struct to construct closure of the PSO can be done by attaching
8/26/11 10:02:04 PM

several screws to a rod on the superior segment and doing the
same at the caudal segments. The two rods can then pass
through a domino-style connector, and this can be closed by
pulling on each rod construct and allowing closure at the con-
nector. The connector can then be locked. The authors then
prefer to remove the temporary rods and connectors, one at a
time to avoid loss of correction and replace them with single
rods on each side. In doing this, there is more room for graft-
ing and less metal bulk (Fig. 92.10).
The PSO is most useful for correcting a sharp, angular
kyphosis or for correcting a severe sagittal imbalance (15 cm)
(Fig. 92.11).2 Approximately 25 to 45 of correction can be
achieved per osteotomy.9,16 A PSO is less optimal in an area with
motion and intact disc spaces. There is a much higher level of
pseudarthrosis due to the large posterior defect. In such cases,
elective anterior fill in procedures in the anterior column are
LWBK836_Ch92_p962-969.indd 967
Chapter 92 Spinal Deformity in the Older Patient With Kyphosis 967
Figure 92.9. The left figure demon-
strates the pedicle subtraction osteot-
omy resection. Note the dura and
roots. The figure on the right demon-
strates compressors being used bilater-
ally for a controlled closure.
recommended to gain ankylosis. When there is already a poste-
rior fusion or circumferential fusion, this is not necessary.13
The PSO is normally done in the lumbar spine but can be done
in the thoracic spine. In the thoracic spine, the correction is
much more limited because of the smaller vertebral body size.
As such, a VCR is usually a better choice for large corrections in
the thoracic spine, and SPOs are a lower risk choice for smaller
and multilevel smooth corrections.
Vertebral Column Resection
VCR is an extension on the concept of PSO. This three-column
resection removes the entire vertebral body and the disc above
and below it. With no anatomic pivot, it is essential that a struc-
tural surgical pivot be inserted to provide an axis of rotation for
this highly unstable but powerful osteotomy. VCR is typically
Figure 92.10. Pedicle subtraction
osteotomy posterior resection through
a fusion mass. Note the closure from
36 mm to 1 mm. This achieves the cal-
culated correction and optimum bone
closure for better healing. The asym-
metry of the resection is to achieve a
combination of sagittal and coronal
correction in this case.
8/26/11 10:02:05 PM
 968 Section VIII Adult Spinal Deformity

of the unstable nature of the osteotomy. The vertebral body is

Figure 92.11. An example of a fixed sagittal deformity on the left
due to an iatrogenic flat back. The image on the right is post-PSO
and achieved normalization of sagittal balance and a dramatic
functional improvement for the patient.
then removed, preserving the posterior cortex. Removal is
done with curettes and drills. If needed, the thoracic roots
below T2 can be sacrificed proximal to the ganglia to help with
access. This is often not necessary but, when done, should have
double ligation of the dura to avoid cerebrospinal fluid leak-
age. The bony removal should include the anterior vertebral
body, or this can be eggshell thinned. At this point, the disc at
the superior and inferior aspects of the resected body should
be removed, preserving the end plates of the adjacent vertebral
bodies. With this done, the posterior vertebral body wall is
removed by fracturing it forward into the defect as described
for the PSO. At this point, meticulous care should be taken to
ensure that all bone and disc material are free of the dura for
closure. Once the bony resection is complete, the defect should
be closed by a third to a half with compression of the temporary
rod construct. Construct to construct closure, as described in
the PSO section, is often done. At this point, a pivot of a variety
of structural materials is filled with graft and placed anteriorly
in the resection site. The final closure is then done, by using
the pivot as a fulcrum. Typically, 2 to 3 cm of posterior closure
is achieved. Permanent rods are placed and circumferential
grafting is performed (Fig. 92.12).
The amount of correction is heavily dependent on the
amount of focal kyphosis that is present preoperatively.
Typically, the spine in the area of resection can be taken from
kyphotic to neutral. Pushing to actual lordosis in the thoracic
spine is ill advised and is not anatomically normal. If additional

done in the thoracic spine for angular correction or in situa-

tions where there has been a prior surgical fusion. In this
region, VCR is superior to PSO due to the shape and size of the
vertebral bodies. The triangular-shaped vertebral bodies of the
thoracic spine do not provide a robust anterior anatomic pivot
point when a PSO is attempted. All too often, the result is a
planum fracture and inadequate sagittal correction when a
PSO is done in the thoracic region. (already said).
The VCR technique is essentially the similar to that described
for a PSO. In view of this, we will emphasize the differences and
minimize discussion on the similar aspects of the procedure.
The VCR is begun with a laminectomy that includes the seg-
ment of the resection and the segments above and below the
planned resection. This is to avoid the development of stenosis
at a spinal cord level during closure. Again, all bone is saved for
later grafting. Approximately 2 to 3 cm of the proximal aspect
of the ribs at the cephalad and caudal end of the resection site
are removed after dissecting the pleura free. The rib head is
then dissected and removed at the cephalad end. Often, only
the superior aspect of the caudal rib head must be removed. If
the pleura is violated, it can be repaired primarily and/or cov-
ered with wet Gelfoam. A positive-pressure ventilation is given
at the end of closure and chest tubes are rarely needed, but
pneumothorax size should be carefully monitored postopera-
tively. After rib removal, the pedicle and facet joints are removed
as described in a PSO. The vertebral body is subperiosteally dis- A B
sected and, when necessary, the segmental vessels can be sacri-
ficed. At this point, temporary rods should be placed because Figure 92.12. Pre- and postvertebral column resection.

LWBK836_Ch92_p962-969.indd 968 8/26/11 10:02:10 PM

 Chapter 92 Spinal Deformity in the Older Patient With Kyphosis 969

comorbidities. In a comprehensive review of the literature,

Elderly patient with Cloyd et al4 found that clinical outcomes after spinal surgery in
kyphosis
the elderly were in general similar to those of younger
patients.
In general, age has not been shown to be a factor in prevent-
Asymptomatic or Symptomatic (pain, ing eventual successful outcome. Patient selection and restora-
minimally progressive deformity, tion of sagittal alignment remain the two most critical factors in
symptomatic neurological deficit
successful spinal reconstruction at any age.

Nonoperative
Surgical treatment
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