The term Spinal deformity refers to a pathological curvature of spine in sagittal or coronal

plane.Spinal Osteotomies are performed for correction of troublesome spinal deformities that are
not correctable with the use of instrumentation alone or where facet or ligament releases are
insufficient to gain enough flexibility. Usually these osteotomies are made at upper lumbar levels as
spinal canal here is wide and osteotomy can be kept distal to the cord end.

The main types of osteotomies are:-

- Smith-Petersen osteotomy (SPO),

- Pedicle subtraction osteotomy (PSO),
- Bone-disc-bone osteotomy (BDBO) and
- Vertebral column resection (VCR),
<in order of increasing complexity>

SMITH PETERSON OSEOTOMY

The procedure was first described by Smith Peterson in 1945 and is simplest of all osteotomies.

It’s a posterior column multiple level spinal extension osteotomy where posterior ligaments, pars
and facets joints are removed and anterior part is opened closing the posterior end using the
posterior annulus (disc) as pivot. A mobile anterior disc is essential to achieve correction in this
procedure.

It should be considered for patients with a C7plumbline that is in the range of 6 cm to 8 cm

positive.

Approximately 10 degrees of correction can be obtained for every 10 mm of bone resected.

Both coronal and sagittal correction can be performed.

The main pitfall is that removal of facets and compression to correct kyphosis leads to a decrease
inforaminal height which may at times lead to nerve rootimpingement.A wide facetectomy can solve
this issue.

PEDICLE SUBTRACTION OSTEOTOMY

This procedure was first described in 1985 first by Thomasenet al.

Normal sagittal alignment of the spine follows a vertical axis from the centre of C2, in front of T7,
behind L3 and to the posterior margin of the sacrum. Forward displacement of C7 in relation to the
pelvis may be caused by deformity in the cervical, thoracic or lumbar regions or fixed hip flexion.The
goal of this surgery is to place the centre of C7 over the posterosuperior aspect of S1 vertebral body
so that a plumbline passes through both.

In PSO, resection of the posterior elements is performed, a triangular wedge through the pedicles is
removed and decancellation of the vertebral body is done via the transpedicular route. Closure of
the posterior part is done using the anterior margin (cortex) of the vertebral body as a pivot.
While Thomasen et al. suggested removal of vertebral body using osteotome, Heining suggested
resection of the vertebral body withthe ‘eggshell’ technique.

It’s a single level osteotomy (so safer than SPO) and is best performed at the apex of the deformity,
whereby, more than 30-40 degrees of correction can be obtained.

While the posterior and middle columns shorten, this osteotomy does not lengthen the anterior
column, does not create an anterior bone defect and provides a more stable correction than SPO.

Both coronal and sagittal correction can be performed and the osteotomy can even be used in
patients with a previous 360° fusion of the spine (SPO cannot be performed in such cases).

Its best suited for patients with sagittal imbalance > 4cms. The ideal candidates for PSO are patients
with type 2sagittal deformity and a substantial sagittal imbalancemore than 12 cm (SVA > 12 cm)
with a sharp, angularkyphosis, and those patients who have circumferentialfusion over multiple
segments, which would precludeperforming SPOs.

Transient neurological deficits have been reportedup to 20% of cases with PSO.

Pseudoarthrosis is a late complication. Posterior mid-line fusion is unlikelybecause of laminectomies.

Posterolateral fusionmust therefore be done after decorticating transverseprocesses appropriately.

BONE DISC BONE OSTEOTOMY

BDBO is an osteotomy done both above and below a disclevel and the resection includes the disc
with its adjacentend-plate(s).

Correction of 35-60 degrees can be achieved, and hence BDBO can be considered insevere sagittal
plane deformities that necessitate correction rates exceeding those that a simple PSO can provide.

The advantages of BDBO compared with PSO include:

correction of the deformity at its apex (CORA), especiallywhen the apex is at the disc space;
potential decrease in pseudoarthrosis rate due todisc removal;
and better stability

A BDBO may be impossible or hard to apply in ankylosingspondylitis patients when the anterior
annulusis calcified or ossified. Aetiology must be kept inmind when selecting the type ofosteotomy.

VERTEBRAL COLUMN RESECTION

Performinga circumferential VCR approach for severe, rigidspinal deformity was first described by
Bradford in the late1980s.

Although VCR is primarily indicated for a fixed coronal plane deformity (for which the commonest
reason is a post surgically treated idiopathic scoliosis), it can also be used for sharp angulated
deformities or rigid multi-planar deformities resulting from hemivertebra resections, spinal tumour
resections,traumatic deformities orspondyloptosis.
Depending on the familiarity of the surgeon with varioustechniques, a VCR can be done as an AP
procedure ora posterior-only procedure.

In order to achieve balance, the spine must not only beshortened but also translated. This requires
resection of the vertebral body.

Neurological deficit from spinal subluxations, over-shortening of the anterior column and buckling of
the spinal cord.All bone anterior to the posterior longitudinal ligament(PLL) must be resected to
prevent buckling ofthe PLL and subsequent anterior compression ofthe spinal cord.