CHAPTER
96
Vertebral Column Resection
for Complex Spinal Deformity:
Posterior Approach
BACKGROUND AND HISTORY
Spinal deformity is a three-dimensional deficit. It includes dec-
ompensation in the coronal and the sagittal plane that results
in a deranged trunk balance. In rigid severe spinal deformities,
conventional correction methods, such as posterior correction
with segmental pedicle screw fixation or anterior release and
posterior instrumentation, are usually unsatisfactory. A more
aggressive approach such as vertebral resection may be neces-
sary. Since vertebral resection was first illustrated in 1922 by
MacLennan,9 several authors68,10,16 have reported their experi-
ences with this procedure, mostly for congenital scoliosis. In
the 1980s, Heinig4 reported the eggshell procedure for the cor-
rection of sagittal and coronal deformity.
VERTEBRAL COLUMN RESECTION
In rigid complex spinal deformity with decompensation,
translation of spinal column is necessary for restoration of
trunk balance and deformity correction. However, angular
osteotomy does not allow translation of the spine. Vertebral
column resection (VCR) is the only option available to correct
translation.
Leatherman7 introduced a two-stage anterior and posterior
corrective procedure for congenital spinal deformity. Bradford
and Boachie-Adjei2 reported one-stage anterior and posterior
resection of hemivertebra. Later, Bradford1,3 reported one-
and two-stage anterior and posterior vertebral column resec-
tion (PVCR) for the treatment of rigid deformity. The proce-
dure was more extensive than vertebrectomy for congenital
hemivertebra. Kostuik5 presented a single-stage anterior and
posterior vertebral resection for correction of iatrogenic lum-
bar kyphosis.
VCR is a last resort technique in the present surgical arma-
mentarium. It is reserved for the most tenacious spinal defor-
mities that cannot be brought to an acceptable range of correc-
tion with less aggressive methods of posterior or combined
procedures.
LWBK836_Ch96_p999-1014.indd 999
Se-Il Suk
VCR differs from spinal osteotomy in that the former resects
discs and endplates above and below creating an unsupported
anterior gap in the vertebral column. The gap must be sup-
ported by additional reconstruction. It can be done at multiple
levels and may correct deformities greater than 50. In the
osteotomy procedures, the gaps are closed by apposition of the
osteotomy surfaces.
The VCR is theoretically very appealing, but it is a challeng-
ing procedure and is an arduous undertaking for both the
patient and the surgeon. It requires an exhaustive and lengthy
operation with a great risk of major complications.
POSTERIOR VERTEBRAL COLUMN
RESECTION
VCR has been performed by combined anterior and posterior
procedures in two separate stages or in one stage. The one-
stage operation is an arduous procedure and involves a long
operating time, is exhausting for the surgeons, and carries a
high risk of injury to the thoracic or abdominal viscus. To avoid
these technical difficulties, in 1997, the author developed a
one-stage PVCR. This procedure necessitated pedicle screw
instrumentation and anterior column reconstruction and was
devised for the correction of a rigid spinal deformity. This
resulted in a reduced operating time, surgeon fatigue, and
fewer complications when compared with of the lengthy com-
bined procedures. PVCR also differs from the conventional
combined anterior and posterior VCR in the usage of the spi-
nal instrumentation, mode of intraoperative deformity correc-
tion, and method of spinal reconstruction.1114
The long-arm reduction screws were used to bring the verte-
bral column gradually to the precontoured rods that were
sequentially changed from those with minimal correction to
moderate correction and finally to the desired shape. The long-
arm reduction screw had the advantage that it is easy to insert
the rod into the screws and it reduces screw failure during
deformity correction. Segmental pedicle screw fixation resulted
in rigid fixation and fewer fusion levels.
999
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 1000 Section VIII Adult Spinal Deformity

INDICATIONS AND ADVANTAGES post-infectious kyphosis, neuromuscular, neurofibromatosis,

OF PVCR fracture, tumor, degenerative, etc (Figs. 96.196.8).
The PVCR has a number of advantages:
PVCR is indicated for almost all types of fixed rigid complex 1. Reduction in the total operating time and the amount of
spinal deformities: congenital and adult scoliosis or kyphosis, blood loss.

A B C

D E F

Figure 96.1. (A, B, C, D) This 2-year-old child had congenital hemivertebra L3 that was treated with hemiver-
tebra resection including discs and endplates above and below (PVCR), and fixed with monosegmental pedicle
screws. (E, F) There was no iatrogenic spinal stenosis with axial CT in postoperative 3- and 6-year follow-ups.

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 Chapter 96 Vertebral Column Resection for Complex Spinal Deformity: Posterior Approach
A B
D E
2. The application of long-arm reduction screws maintains
spinal stability and prevents intraoperative complica-
tions during resection and correction of the spinal
deformity.
3. More reliable reconstruction of the spinal column ensuring
continuous anterior structural support.
LWBK836_Ch96_p999-1014.indd 1001
1001
C
Figure 96.2. (A, B and C) This 34-year-old
woman who had kyphoscoliosis with congenital
hemivertebrae at L1 and L2 was treated with
PVCR at L1 and L2 and fixed with pedicle
screws from T10 to L4 with an anterior mesh
cage. (D, E) Scoliosis was corrected from 60 to
20 and kyphosis from 85 to 23 with balanced
spine in postoperative 2 years.
4. Less postoperative morbidity than the combined procedure
that allows patients with reduced pulmonary function to
undergo the correction.
5. More effective correction of the deformity and trunk
imbalance.
6. Allows direct visualization and protection of neural elements.
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 1002 Section VIII Adult Spinal Deformity

A B C D

E F

Figure 96.3. (A, B, C, D) This 41-year-old man with adult scoliosis was treated with PVCR at T9 and fixed
with pedicle screws from T3 to L2 with an anterior mesh cage. Thoracic curve was corrected form 116 to 55
and lumbar curve from 66 to 50. (E: preoperative, F: postoperative) Medical photos showed satisfactory
correction of the deformity with well-balanced trunk.

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 Chapter 96 Vertebral Column Resection for Complex Spinal Deformity: Posterior Approach 1003

A B C

D E F

Figure 96.4. (A, B, C, D) This 16-year-old girl with neuromuscular scoliosis was treated with PVCR of T10
and T11 with pedicle screw instrumentation from T3 to L5. Thoracic scoliosis was corrected from 124 to 79
and thoracolumbar kyphosis from 70 to 24. (E: preoperative, F: postoperative) Medical photos showed that
her trunk was well balanced and she could sit without hand support in postoperative 2-year follow-up.

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 1004 Section VIII Adult Spinal Deformity

A B C

D E F

Figure 96.5. (A, B, C, D, E) This 30-year-old woman with postinfectious kyphosis at thoracolumbar level
was treated with PVCR of 5 vertebrae (T10 to L2) and fixed with pedicle screws from T7 to L5. (F) Medical
photo showed satisfactory deformity correction.

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 Chapter 96 Vertebral Column Resection for Complex Spinal Deformity: Posterior Approach 1005

A B C

D E

Figure 96.6. (A, B, C) This 49-year-old woman who had lumbosacral kyphosis of 54 with pain and weak-
ness of both lower extremities for 1 year was treated with PVCR of L3, L4, and L5 and fixed with pedicle
screws from T11 to S2 and an anterior mesh cage. Kyphosis was corrected to lordosis of 1. (D) This diagram
shows resected vertebrae and pedicle screw instrumentation. (E) The patient stands straight and her neurol-
ogy improved postoperatively.

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 1006 Section VIII Adult Spinal Deformity
A B
D E
SUMMARY OF AUTHORS
PAPERS ON PVCR
The author13 reported 70 spinal deformity patients treated by
PVCR with minimum follow-up of 2 years in 2002. The mean
age was 27.4 years. Etiologies were adult scoliosis in 7, congeni-
tal kyphoscoliosis in 38, and postinfectious kyphosis in 25
LWBK836_Ch96_p999-1014.indd 1006
C
Figure 96.7. (A, B, and C) This 35-year-
old woman who had metastatic breast cancer
at T2 with progressive paraparesis for 1
month was treated with PVCR of T2 and
fixed with pedicle screws from C7 to T5.
(D, E) Paraparesis disappeared and she walks
well in postoperative 3 years.
patients. The total number of resected vertebrae was 143
(76 thoracic and 67 lumbar). Mean operating time was 4 hours
and 31 minutes with average blood loss of 2,333 mL. The defor-
mity correction was 62% in the coronal plane and 45 in the
sagittal plane. Complications were encountered in 24 patients:
2 complete cord injuries in severe kyphoscoliosis patients who
had preoperative cord compromise, 4 incomplete root injuries,
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 Chapter 96 Vertebral Column Resection for Complex Spinal Deformity: Posterior Approach
A B
D E
6 hematomas, 5 failures of fixation, 5 hemopneumothoraces,
and 2 infections.
The author11 also reported PVCR in 16 severe rigid scoliosis
patients (average age 29 years) in 2005. The number of verte-
brae removed averaged 1.3 for a total of 21 (15 thoracic and 6
lumbar). Average number of vertebrae fused was 10.6. The
mean preoperative scoliosis of 109 was corrected to 63 (59%
LWBK836_Ch96_p999-1014.indd 1007
1007
C
Figure 96.8. (A, B, and C) This
59-year-old woman had L1 fracture 1
year ago and had progressive kypho-
sis and weakness in both lower
extremities for 6 months. (D, E)
This patient was treated with PVCR
of L1 and fixed with pedicle screws
from T10 to L3 with an anterior
mesh cage.
correction), and the minor curve of 59 was corrected to 29
(51% correction). The preoperative coronal imbalance of 4.0
cm was improved to 1.0 cm, and sagittal imbalance of 4.2 cm
was improved to 1.6 cm. There were complications in four
patients; one complete paraplegia who had preoperative neu-
rology and other three were minor complications. The author12
also reported PVCR in 25 fixed lumbosacral deformity patients
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 1008 Section VIII Adult Spinal Deformity
in 2005. Fifty-two vertebrae were removed ranging from 1 to
5 vertebrae. Preoperative scoliosis of 38 was corrected to 15
(60% correction), and preoperative kyphosis of 35 was cor-
rected to 5 (40% correction). Mean operating time was
280 minutes with a blood loss of 2, 810 mL.
SURGICAL TECHNIQUES
The resection in each case was performed at the apex of the
deformity to increase the effectiveness of the resection. The
number of vertebrae removed was determined by the type of
the deformity and the desired correction to restore the trunk
balance. In the adult scoliosis, one vertebral resection would
correct approximately 50 of scoliosis. The fusion in this defor-
mity was usually performed from one level above the upper end
vertebra of index curve to one level caudal to the lower end
vertebra of the index curve. In the congenital kyphoscoliosis,
all the anomalous vertebrae were resected and all the vertebrae
in the index curve were fused. In the postinfectious kyphosis,
all the fused vertebrae were resected and fusion was carried out
from three vertebrae above the resection to two vertebrae below
the resection in most of the patients.
All patients were monitored intraoperatively using soma-
tosensory evoked potentials (SSEP) or motor evoked potentials
(MEP).
POSITIONING AND ANESTHESIA
The patients were placed in prone position on a Jackson table
under general anesthesia using intraoperative SSEP or MEP
monitoring.
A B
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INCISION AND EXPOSURE
The incision was a straight posterior midline or curvilinear inci-
sion depending on the type and size of the deformity. The verte-
brae between the uppermost and the lowest instrumented
vertebrae were exposed to the tips of the transverse process by
subperiosteal dissection. The dissection was then carried out lat-
erally, exposing the ribs corresponding to the level of the VCR.
FACETECTOMY
The facets included in the fusion levels were destroyed by infe-
rior facetectomy and removal of the articular cartilage to pro-
mote intra-articular arthrodesis. For the ankylosed or fused
posterior facet joints, no attempt was made to mobilize the
joints at this stage.
PEDICLE SCREW FIXATION
The technique of pedicle screw insertion was as follows.
K-wires inserted at the presumed pedicle entry points
(Fig. 96.9) and then a single PA and lateral intraoperative
radiograph was taken to confirm the location. Placing the pedi-
cle screws before the resection procedure had three functions:
(1) to provide reliable intraoperative stability to the vertebral
column while the destabilization took place, (2) to offer a grip
for the vertebral column for the manipulative correction of the
deformity (3) to provide a marker that was traceable by radiog-
raphy for determining the position and the orientation of the
vertebral resection.
For optimal correction of the deformity and maintenance of
the stability, long-arm reduction pedicle screws were inserted
Figure 96.9. (A: PA view, B: lateral
view) K-wires inserted at the presumed
pedicle entry points. The presumed pedi-
cle entry point of the lower thoracic and
lumbar spine is at the junction of the
bisected transverse process and lateral
margin of the facet joint and that of the
upper thoracic spine is at the junction of
superior margin of the transverse process
and lateral aspect to midportion of facet
joint.
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 Chapter 96 Vertebral Column Resection for Complex Spinal Deformity: Posterior Approach 1009

Figure 96.10. (A: PA view, B: lateral view) Long-

arm reduction pedicle screws are inserted segmentally,
A B
except at the resected level.

RESECTION OF THE VERTEBRAL COLUMN

segmentally, except at the resected levels (Fig. 96.10). Short
temporary stabilizing rod was inserted at a level, two screws
above and below on one side and fixed before starting the
resection. The temporary rod was precontoured to the shape of
the deformity without any attempt of correction (Fig. 96.11).
To maximize the effect of the resection, it was carried out at the
apex of the deformity. The temporary rod on the side being
resected was removed while keeping the rod on the opposite
side to maintain rigid fixation. The transverse process and the

Figure 96.11. (A: PA view, B: lateral view) Short

A B
temporary rod contoured to the shape of the deformity
is inserted on one side.

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 1010 Section VIII Adult Spinal Deformity
A B
corresponding rib head were removed to expose the lateral
wall of the pedicle. In the lumbar spine, the transverse process
was osteotomized at its base. The vertebral resection began with
removal of the posterior elements, using a high-speed power
burr, gauge, and Kerrison punch. The gauge was carefully used
to avoid cord contusion and was not used in kyphotic deformi-
ties. Laminectomies were complete and included the neural
arch of the resected vertebrae, and one above and one below.
The nerve root could be easily identified when the neurovascu-
lar foramen was unroofed (Fig. 96.12).
Subperiosteal dissection was deepened following the lateral
wall of the vertebral body until the anterior surface of the ver-
tebral body was comfortably palpable. Under visual control, the
pedicles and the lateral portion of the vertebral body were
removed using a small osteotome and a high-speed power burr.
The vertebral body and the intervening discs were removed in
a piece by piece gradually toward the medial side and over to
the other half of the vertebral body through the void created. A
thin shell of bone of the posterior vertebral wall was preserved
beneath the dural tube. The anterior walls were also removed
in a piecemeal fashion, taking care to leave the soft tissue tube
anterior to the vertebral bodies including the anterior longitu-
dinal ligament intact. As much vertebral body and disc as pos-
sible was removed at this stage, even across the midline, as it
was safe to work with the posterior wall protecting the neural
structures. During the resection of the vertebral body, disc and
lateral body wall, meticulous subperiosteal dissection was per-
formed. This process also ensured the safety of the segmental
vessels. Bleeding was controlled with bipolar electrocautery,
bone wax, and thrombin-soaked Gelfoam. When an adequate
amount of vertebral body was removed, all of posterior verte-
bral wall that was visible lateral to the dural tube was removed
with an Epstein reverse-cutting curette pushing the posterior
LWBK836_Ch96_p999-1014.indd 1010
Figure 96.12. (A: PA view, B: lateral view) Posterior
neural arches, vertebral bodies, and discs above and
below are removed at one side of resected vertebrae.
cortex of the vertebral body into the removed body space.
Following the resection of the posterior wall on the working
side, another temporary rod, contoured to the shape of the
deformity, was inserted to that side. Gentle compression of
pedicle screws then corrected the deformity, avoiding cord ten-
sion. The rod was then securely locked to the screws. The rod
on the other side was removed to allow resection on that side.
The same procedure was carried out on the opposite side
(Fig. 96.13). In resection of thoracic vertebrae, the thoracic
nerve root on one side was cut to facilitate resection of the body
and reconstruction of the anterior column. However, nerve
root on the opposite side was saved when possible. In lumbar
vertebrae, the nerve roots on both sides were kept intact. At the
completion of the resection, the rod that had been removed
was replaced and connected to the screws. Then a final check
of the canal was made to ensure that it was free of any residual
compression at the resection margins, or redundant bony or
disc tissue attached to the anterior side of the dura that might
hinder free, untethered movement of the dural tube.
DEFORMITY CORRECTION
Deformity correction was carried out by compression of the
precontoured temporary rods alternately (Fig. 96.14). Exten-
sion of the operating table was unnecessary. The precontoured
rod was advantageous in reducing the operative time and the
screw failures from force concentration of any specific screw.
To avoid inadvertent distraction of the neural elements, the
vertebral column was initially shortened by slight compression
over the resected gap without tight locking of the opposite tem-
porary rods. Great care was taken to prevent distraction, insta-
bility, and translation. Stability had to be maintained with a
temporary rod on one side at all times. The deformity was
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 Chapter 96 Vertebral Column Resection for Complex Spinal Deformity: Posterior Approach 1011

Figure 96.13. (A: PA view, B: lateral view) Another

temporary rod contoured the shape of the deformity is
inserted on the opposite side. After the previous tempo-
rary rod is extracted, the same resection procedure is car-
ried out on the other side. A B

gradually corrected with the repeated additional compression
and shortening of the vertebral column with sequential replace-
ment of the temporary rods. The compression and shortening
over the resected gap were carried out until the exposed cord
looked relaxed. Impingement of the spinal cord by posterior
sharp edges of the proximal and distal end of the vertebra body
and posterior lamina has to be checked again. For the correc-
tion of scoliosis, the compression and shortening over the
resected gap could be asymmetrical even with more compres-
sion and shortening of the convex side. After compression and

Figure 96.14. (A: PA

view, B: lateral view) Defor-
mity is corrected by compres-
sion of the precontoured
A B
temporary rods alternately.

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 1012 Section VIII Adult Spinal Deformity

shortening of the resected gap, the temporary rods were

changed to precontoured final rods one at a time to avoid any
loss of shortening of the resected gap (Fig. 96.15). The final
rods were precontoured to the normal sagittal curve. The
deformity was corrected by compression.

ANTERIOR AND POSTERIOR ARTHRODESIS

Anterior fusion across the resection gap was carried out, and
posterior fusion was performed at all instrumented levels. For
anterior fusion at the resected area, autogenous cancellous
chip bone graft or a titanium mesh cage was used. After resec-
tion and deformity correction, the height of the anterior inter-
body gap was measured. If the shortest height was less than
5 mm, autogenous cancellous chip bone was placed into the
anterior gap. In cases of anterior gaps more than 5 mm, a
titanium mesh cage filled with autograft was used to provide
reliable anterior column reconstruction without excessive
shortening (Fig. 96.16). Titanium mesh was more convenient
to adjust the size of the interbody gap and had the advantage
of offering additional stability because they were strong enough
to be punched in and serrated at both ends so that they could
be sunk into the bone beds with compression. The best size of
the anterior structural graft would be one that allowed a tight
fit in the anterior gap to effectively support the load and
increase the chance of bony fusion without causing a compres-
sion or undue tension in the neural elements. The mesh cage A B
was inserted from the posterolateral side, through the space
between the nerve roots, to fit on the proximal and distal bone Figure 96.15. (A: PA view, B: lateral view) After compression and
bases. Additional compression over the cage was carried out to shortening of the resected gap, the temporary rods were changed to
lock it into place. Decortication and bone graft were performed permanent final rods. The deformity is further corrected by more
compression.
at fusion levels. Unilateral posterior bridging bone graft was
inserted over the resection gap. Local bone graft was usually
sufficient after vertebral resection and iliac autograft was added for 3 to 4 months and followed by a custom-made plastic
if necessary. thoraco-lumbar-sacral orthosis for an additional 3 months.

WOUND CLOSURE
After grafting three or four closed suction drains were inserted
at the resection site, and the surgical wound was closed in
layers.
AFTERTREATMENT
The patients were allowed to sit up in bed 24 hours after the
surgery. Patients were allowed out of bed with a localizer body
cast at the second postoperative week. The body jacket was kept
COMPLICATIONS
The author15 reported complications treated by PVCR in 152
patients and their overall complications were 39.5% (Table
96.1). The most important risk factors of complications were
preoperative neurologic deficit, kyphosis, and fusion extent
more than five segments. The preoperative neurologic deficit
and multilevel vertebral resection were important two risk
factors in the development of postoperative neurologic compli-
cations. The possible perioperative causes of neurologic injury
could be from excessive retraction, translation, excessive

Etiologies and Complications of Patients (n 152)

TABLE 96.1
Undergoing PVCR

Diagnosis n Complications n
Congenital deformity 91 Minor neurologic deficit 21 (13.8%)
Postinfectious kyphosis 31 Major neurologic deficit 5 (3.3%)
Neuromuscular scoliosis 8 Dura tear 16 (10.5%)
Post-traumatic kyphosis 6 Metal failure/Progressing curve 12 (7.9%)
Adult deformity 4 Wound infection 10 (6.6%)
Others 12 Others 6 (3.9%)
Total 152 Incidence 60 (39.5%)

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 Chapter 96 Vertebral Column Resection for Complex Spinal Deformity: Posterior Approach 1013

Figure 96.16. (A: PA view, B: lateral view) In cases

of anterior gaps more than 5 mm, a titanium mesh cage
filled with autograft is inserted to provide anterior
column reconstruction without excessive shortening. A B

A Translation Temporary rod insertion

B Impingement Resect impinging bone

Figure 96.17. Common causes of

cord damage and prevention: (A)
Translation can be prevented by the
temporary rod fixation before starting
decompression. (B) Impingement has
to be avoided by resection of the
impinging bone to the cord. (C)
Lengthening can be prevented with
intermittent compression of temporary
rod. C Distraction Intermittent compression

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 1014 Section VIII Adult Spinal Deformity
shortening, incomplete resection of bone with cord impinge-
ment, forceful instrumental reduction, cord ischemia, and
postoperative hematoma. To prevent the cord injury, transla-
tion must be avoided by temporary rod fixation, impingement
by the resection of impinging bone, and excessive lengthening
by intermittent compression perioperatively (Fig. 96.17).
CONCLUSION
VCR can be applied effectively in severe and rigid complex
spinal deformity. The advantages are enhanced deformity
correction, easier spine balancing, more effective neural
decompression, and preservation of motion segments, employ-
ing pedicle screw instrumentation. PVCR is an effective alterna-
tive to the conventional anteriorposterior VCR and offers the
following advantages:
1. A one-stage operation through a single posterior incision to
resect the rigid pathologic part including discs and end-
plates.
2. Reduced operating time and bleeding
3. More reliable reconstruction of the vertebral column
4. Reducing complications as compared with those associated
with the separate anterior and posterior approach.
It must be kept in mind that this is a technically difficult pro-
cedure even for highly experienced surgeons, carries significant
LWBK836_Ch96_p999-1014.indd 1014
risks for major complications, and is only indicated in patients
with severe deformity and no other options for stabilization.
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