Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of...
Transcript of Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of...
![Page 1: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/1.jpg)
Adult Spinal Deformity: Principles of Surgical CorrectionS. Samuel Bederman, MD PhD FRCSCDepartment of Orthopaedic Surgery
California Orthopaedic Association, Indian Wells, CAApril 25, 2015
![Page 2: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/2.jpg)
2
![Page 3: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/3.jpg)
3
![Page 4: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/4.jpg)
4
![Page 5: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/5.jpg)
5
Adult Scoliosis: How common is it?
Age > 50: 6-9%
LBP: 7.5%
Both: 15-68%
![Page 6: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/6.jpg)
6
0
1
2
3
4
5
PainFunction
Self-image
Mental H
ealth
Adult Scoliosis
Controls
Impact of Degenerative Scoliosis
![Page 7: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/7.jpg)
7
Adult Scoliosis: Distinct Populations
Lumbar
Degenerative
Adult Idiopathic
Age >50y 30s-50s
Etiology Disc/facet
degeneration
Idiopathic
Reason for
presentation
Leg pain, back pain Deformity, back pain
Curve magnitude 20-30 degrees 50-60 degrees
Stenosis 84% 7%
![Page 8: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/8.jpg)
8Pritchett and Bortel, Spine 1993
Natural History
• Curve progression averaged 3.3 degree per year.
• Those with progression had increased back and leg pain.
![Page 9: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/9.jpg)
9
Clinical Assessment
History
Physical
Imaging• X-rays
• Bending & Traction films
• MRI
• CT scan +/- myelogram
• Discogram
![Page 10: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/10.jpg)
10
History
Pain• Back – more prevalent
• Leg – more commonly the reason for presentation
– Radicular or Neurogenic claudication
Postural Imbalance/Deformity Progression• Stooped Posture
• Coronal imbalance may be painful, fatiguing
• Convexity is the area of greatest pain in 75%
– 2nd most common is concavity
![Page 11: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/11.jpg)
11
Physical Examination
Overall spine alignment
Neurological examination• Many patients have a normal exam
Other joint pathology• Hip/Knee – contractures
– The hip may be maximally extended to
compensate for a loss of lordosis
• Cervical spinal stenosis – altered gait
![Page 12: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/12.jpg)
12
Imaging
Plain Radiographs• Standing PA/lateral full-length spine films
– 14 x 36”
• Lateral supine bending films
• Traction films in curves > 60 degrees
• Push-prone films
• Flexion/Extension for lumbar flexibility and
sagittal instability
• Non-weightbearing imaging (supine
radiographs, MRI) tend to underestimate
curve magnitudes by approximately 10
degrees
Lee, Solomito, Patel. Spine, 2013
![Page 13: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/13.jpg)
13
Dynamic Radiographic Studies
Lateral Bending• Less flexible than adult idiopathic scoliosis
Traction• Can reveal extent of autofusion from degeneration
Left BendRight Bend
![Page 14: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/14.jpg)
Traction Films
Standing PA Supine PA with Traction
![Page 15: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/15.jpg)
15
Advanced Imaging and further testing
Cross-sectional imaging• MRI• CT +/- myelography
?Discography
PFTs• For thoracic curves > 70 degrees• Pulmonary symptoms• Hx of pulmonary disease• Thoracoplasty: 27% decline in PF at 3 months
– Lenke (1995) Spine.
![Page 16: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/16.jpg)
16
The Cone of Economy
![Page 17: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/17.jpg)
17
Coronal and Sagittal Balance
Positive sagittal balance most reliable predictor of clinical symptoms and poor functional outcome in operative and non-operative patients.
Glassman SD, et al. Spine, 2005
![Page 18: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/18.jpg)
18
Pelvic Parameters: Sagittal Plane
![Page 19: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/19.jpg)
19
Pelvic Parameters
PT + SS = PI
![Page 20: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/20.jpg)
20
Compensation with Pelvic Retroversion
↑ Imbalance
↑ Compensation
=
↓ Quality of
Life
Similar functional outcome improvements in compensated and uncompensated flatback deformities following surgical correction
Smith JS, et al. J Neurosurg Spine, 2014
![Page 21: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/21.jpg)
21
Pelvic Compensation
![Page 22: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/22.jpg)
22
Reciprocal Changes around the Hip and Pelvis
![Page 23: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/23.jpg)
23
Reciprocal Changes around the Hip and Pelvis
![Page 24: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/24.jpg)
24
Reciprocal Changes: Pelvic Compensation
Retroversion Anteversion
Posterior
Impingement
Anterior
Impingement
![Page 25: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/25.jpg)
25
Knee Flexion Contractures
![Page 26: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/26.jpg)
26
Case Example
75F
Back and leg pain
Unable to stand upright
Prior ACDF C3-7
![Page 27: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/27.jpg)
27
![Page 28: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/28.jpg)
28
PI = PT+SS
PT < 25
PI = LL
PI=62 PT=33
SS=29
LL=26
TK=52
SVA=14cm
•PI-LL = 62-26=36
Treatment???
![Page 29: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/29.jpg)
29
Surgical Decision Making
General Indications
Pain
Neuro deficit
Deformity
Surgical Options
Decompression
Stabilization
Deformity correction
![Page 30: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/30.jpg)
30
Stand-Alone Decompression
Rarely indicatedNo back painNo up-down foraminal stenosisNo gross instability at selected levels
Stability preservingLaminotomyUnilateral approach for bilateral decompression
McCullough laminoplasty, Spinous process osteotomy
![Page 31: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/31.jpg)
31
Minimally Disruptive Approaches
![Page 32: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/32.jpg)
32
Decompression/Limited Fusion
Limited fusion with decompressionShort segment
Interbody for height restoration
Fusion w/o correction if balanced in coronal and sagittal plane
Especially below a rigid or fused curve
Risk of adjacent segment disease
Risk of progression of deformity
![Page 33: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/33.jpg)
33
Deformity Correction
Addresses all anatomical causes of pain – deformity, degeneration, and neural element compression
Decreases likelihood of revision to address problems within the deformity
May still have risk of adjacent segment disease
Higher amount of overall morbidity
![Page 34: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/34.jpg)
34
Controversy: Decompression vs. Limited Fusion vs. Correction
85 patients with degen scoliosis and radiculopathy
Treated by decompression, decompression and limited fusion, decompression and curve correction
All 3 had good and poor results• D: fewest complications, most would not have done again• DCC: highest complications, most successful• DLF: in between
![Page 35: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/35.jpg)
35
The Good News
Leg pain is reliably treated operatively when compared with non-operative treatmentSmith, et al. Spine 2009
Back pain is reliably treated operatively when compared with non-operative treatmentSmith, et al. Neurosurgery 2009
Good deformity correction can be achieved surgicallyPateder, et al. Spine 2007
![Page 36: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/36.jpg)
36
Functional Improvement
Patients consistently walk and stand better than pre-op
They usually tolerated sitting the same or better than pre-op
Pain was consistently reduced in patients w/ successful fusion
Spine 2004
![Page 37: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/37.jpg)
37
The Bad News
Major Complications
Residual pain 5-15%
Neurologic injury Up to 5%
Infection 1-5%
Pseudarthrosis 5-27%
Thromboembolism 1-20%
![Page 38: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/38.jpg)
38
Rates of Complications, by Age Group, SRS Database
• Studies found surgical complications for scoliosis ranging from 10-40%
• 25-44 years (n = 47 cases) = 17% developed complications
– Highest major complication: deep wound infection (25% major
complications)
• 45-65 years (n = 121) = 42%
– Highest minor complications:
• cerebrospinal fluid leak (8% minor complications)
• symptomatic pulmonary effusion (8%)
• prolong ileus (6%)
– Highest major complications:
• excessive blood loss (22% major complications)
• deep wound infection (22%)
• nerve root injury, quad weakness (17%)
Source: (Smith, Shaffrey, Glassman, et al., 2011)Department of Orthopedic Surgery
![Page 39: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/39.jpg)
39
Rates of Complications, by Age Group, SRS Database
• 65-85 years (n = 38) = 71%
– Highest minor complications:
• superficial infection (25% minor complications)
• deep venous thrombosis (19%)
• prolonged ileus (19%)
– Highest major complications:
• excessive blood loss (37% major complications)
• deep wound infection (18%)
• pulmonary embolism (18%)
Smith, Shaffrey, Glassman, et al., Spine, 2011
Department of Orthopedic Surgery
![Page 40: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/40.jpg)
The Evolution of Scoliosis Treatment
Orthopaedic“Straight child”
![Page 41: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/41.jpg)
41
The Evolution of Treatment
Hippocrates
Hibbs
Paré
![Page 42: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/42.jpg)
42
The Instrumentation Era
Harrington
Cotrel Dubousset LenkeSuk
![Page 43: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/43.jpg)
43
Techniques of Correction
Compression on convexity creates lordosis
Distraction on concavity creates kyphosis
M/L Translation
Rod Rotation
![Page 44: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/44.jpg)
44
Unique Considerations in Adults
Stenosis
Disc Degeneration
Joint Ankylosis
Osteoporosis
Risk of Nonunion
Medical Comorbidities
![Page 45: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/45.jpg)
45
![Page 46: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/46.jpg)
46
Adult Deformity Techniques for Sagittal Imbalance
Lengthen the frontInterbody fusion (TLIF, XLIF, ALIF)
Shorten the backFacetectomy, SPO
PSO or VCR (for significant or focal deformity)
Or Both!! (anterior and posterior)
Asymmetric Corrections for Coronal Deformity
![Page 47: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/47.jpg)
47
Interbody Fusions
![Page 48: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/48.jpg)
48
Posterior Shortening Procedures
Osteotomies
![Page 49: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/49.jpg)
49
Smith-Peterson Osteotomy (SPO)
Facetectomy with resection of posterior elements through foramina
Hinges on PLLShortens the neuroforamenOpens at the disc space
Requires a mobile disc!!!
10-15 degrees per level
Better for global correction
Can be done at multiple levels
![Page 50: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/50.jpg)
50
Pedicle Subtraction Osteotomy (PSO)
Resection of posterior elements including bilateral pedicles of a single vertebral body
Closing wedge osteotomy of a vertebraHinges on anterior column
Can be done through rigid spine
35-50 degrees per level (L-spine)
![Page 51: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/51.jpg)
51
Vertebral Column Resection (VCR)
Resection of entire vertebra with discs above and below from posterior approach
Typically requires insertion of interbodydeviceHinges on anterior column which may be
lengthenedCan be done through rigid spine40-60 degrees per levelMost destabilizing = highest risk of
complications
![Page 52: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/52.jpg)
52
Approach to Deformity Correction
Plane of deformity
sagittal, coronal, axial
Global vs. Focal deformity
Rigid vs. Flexible
Mild vs. Severe
Bone Quality
Choosing the ends of the construct
![Page 53: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/53.jpg)
53
Case Example
75F
Back and leg pain
Unable to stand upright
Prior ACDF C3-7
![Page 54: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/54.jpg)
54
PI = PT+SS
PT < 25
PI = LL
PI=62 PT=33
SS=29
LL=26
TK=52
SVA=14cm
•PI-LL = 62-26=36
![Page 55: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/55.jpg)
55
Case Example
Stage 1: L1-L5 XLIF
Stage 2: T10-P PSF
![Page 56: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/56.jpg)
56
PI=62
SVA=0
PT=19
LL=68
TK=60
![Page 57: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/57.jpg)
57
Case – 68M
Parkinson’s
Previous L4-5 Decompression
Progressive kyphosis
CamptocormiaPostlaminectomy kyphosis
![Page 58: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/58.jpg)
58
![Page 59: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/59.jpg)
59
![Page 60: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/60.jpg)
60
![Page 61: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/61.jpg)
61
• Hx of Degen Scoliosis
• Underwent MIS Scoliosis correction• L1-L5 XLIF
• Bilateral Wiltse Fusion
L1-S1
• MIS TLIF @ L5-S1
• After surgery:• Increased back pain
• Unable to stand
straight
Case – 81F
![Page 62: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/62.jpg)
62
Case – 81F
![Page 63: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/63.jpg)
63
• L3 PSO
• Revision L5-S1 TLIF
• Dual Iliac screws
• T10-Pelvis PSF
Case – 81F
![Page 64: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/64.jpg)
64
Case – 81F
![Page 65: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/65.jpg)
65
![Page 66: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/66.jpg)
66
Case – 61F
Prior surgery x 2
T7-S1 PSF
Can’t stand up straight
Back and leg pain
Using a walker to ambulate
Smoker
Heavy dose narcotics
![Page 67: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/67.jpg)
![Page 68: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/68.jpg)
![Page 69: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/69.jpg)
![Page 70: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/70.jpg)
70
Diagnosis
Sagittal and Coronal Imbalance
Spinal Stenosis
Pseudarthrosis
Broken rod
S/P T7-S1 PSF
![Page 71: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/71.jpg)
71
L4 Asymmetric PSO with TLIF cage, T4-Pelvis PSF
![Page 72: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/72.jpg)
72
Post-op
![Page 73: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/73.jpg)
![Page 74: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/74.jpg)
![Page 75: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/75.jpg)
75
Summary
Important to understand how to:
•Recognize and Assess Adult Spinal Deformities (Coronal, Sagittal, Combined) and understand the burden of disease
•Quantify Magnitude and Planes of Deformity to Plan for appropriate correction
•Anticipate potential for reciprocal changes after correction
•Minimize Complications while Achieving Treatment Goals
![Page 76: Adult Spinal Deformity: Principles of Surgical Correction · Adult Spinal Deformity: Principles of Surgical Correction S. Samuel Bederman, MD PhD FRCSC Department of Orthopaedic Surgery](https://reader034.fdocuments.net/reader034/viewer/2022042622/5f7d4efeeaca37592e18a8fe/html5/thumbnails/76.jpg)
Thank You!