SPINE Volume 31, Number 19 Suppl, pp S161–S170
©2006, Lippincott Williams & Wilkins, Inc.
Thoracic and Thoracolumbar Kyphosis in Adults
Angel E. Macagno, MD, and Michael F. O’Brien, MD
Study Design. Author experience and literature re-
view.
Objectives. To investigate the spectrum of adult ky-
phosis and to discuss the various surgical and nonsurgi-
cal treatment options.
Summary of Background Data. Kyphosis with its var-
ious etiologies and associated pathophysiologies has
been discussed in the literature for many decades. The
nonsurgical treatment primarily consists of symptom re-
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duction via physical therapy and has not changed signif-
icantly for decades. The surgical treatment, however, has
changed dramatically. A decade ago, most large kyphotic
deformities required anterior and posterior procedures.
With the advent of numerous posterior osteotomy tech-
niques and pedicle fixation, most of these deformities are
now treated via posterior methods only.
Methods. Using literature review and the author’s expe-
rience, kyphosis and its characteristics will be discussed.
Important details pertinent to presurgical planning and ex-
ecution of surgical will be discussed. Three cases will be
presented to illustrate the surgical treatment options for
three qualitatively different kyphotic deformities.
Results. Flexible kyphotic deformities may respond well
to aggressive facetectomies and cantilever corrections. Mul-
tisegmental osteotomies may be most appropriate for long
sweeping deformities. Fixed, sharply, angulated deformities
may respond best to pedicle subtraction osteotomies or
vertebral column resections.
Conclusion. Segmental pedicle screw fixation coupled
with one of four posterior osteotomy/resection tech-
niques can be used to address most sagittal plain defor-
mities. Careful application of these techniques is impor-
tant. Smith-Petersen and Ponte osteotomies are most
appropriate for long sweeping deformities with mobile
anterior columns. Pedicle subtraction osteotomies and
vertebral column resections are most appropriate for
fixed, sharply angulated spinal deformities. The success-
ful application of these techniques is dependent on accu-
rate preoperative evaluation of the structural properties
of the kyphosis and meticulous execution of the surgical
technique.
Key words: kyphosis, adults, classification, evaluation,
treatment, osteotomies. Spine 2006;31:S161–S170
Coronal plane deformities have been the focus of spinal
surgeons for many years. The importance of sagittal
plane alignment has only recently been appreciated in
relation to the short- and long-term outcome after spinal
From the Miami Children’s Hospital, Department of Orthopedic Sur-
gery, Center for Spinal Disorders, Miami, FL.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to Angel E. Macagno,
MD, Miami Children’s Hospital, Department of Orthopedic Surgery,
Center for Spinal Disorders, 3100 S.W. 62nd Avenue, Miami, FL
33155-3009; E-mail: angel.macagno@mch.com
deformity correction. Because of underestimation of the
importance of the sagittal plane, we have both created
and overlooked these deformities.
Many kyphotic deformities treated in adulthood arise
from pediatric pathologies, such as congenital kyphosis
and Scheuermann’s kyphosis. However, a host of other
pathologies may develop or become symptomatic in
adulthood or may be particular to the adult patient.
These include senile kyphosis secondary to osteoporotic
burst or compression fractures, post laminectomy syn-
drome, inappropriate surgical procedures resulting in
flatback phenomenon, neurofibromatosis, ankylosing
spondylitis, and degenerative disease.1 Whatever the eti-
ology, the ultimate result is loss of sagittal alignment
causing back pain, structural instability, or clinical mal-
alignment.
Classification of Kyphotic Deformities
Numerous classifications have been proposed for kypho-
sis over the years. Some classifications are based on
pathologic diagnosis (Table 1). Other classifications are
based on structural abnormalities observed on radio-
graphs, such as congenital deformities (Table 2). Tho-
racic and thoracolumbar kyphosis has been associated
with many pathologic entities, including Scheuermann’s
disease,2 congenital vertebral malformation, paralytic
conditions, and posttraumatic and inflammatory condi-
tions. A particularly aggressive and dangerous form of
kyphosis may develop in patients with neurofibromato-
sis and osteogenesis imperfecta.
While these classification schemes may identify an as-
sociated pathology or help describe the underlying struc-
tural etiology of the deformity, they do not help plan
surgical treatment. A more simplistic structural evalua-
tion must be undertaken by the surgeon when planning
for surgery, namely, what is required to return the spine
to its normal sagittal contours. In addition, the presence
of axial and/or coronal plain deformities will need to be
considered in the overall plan to treat these sagittal ma-
lalignments. The cervical and the lumbar sagittal and
coronal plane issues must also be considered when ad-
dressing the thoracic kyphosis. Important deformity pa-
rameters requiring evaluation include the size, shape,
and length of the kyphosis. Part of this evaluation will
ascertain whether the primary kyphotic deformity is a
regional/global deformity, covering the entire thoracic,
thoracolumbar, or lumbar spine or if the deformity is
more segmental/focal covering one or two segments.
These distinctions are important to consider since a well-
balanced segmental kyphotic deformity may be ignored
as well might a more global thoracic kyphosis, which
leaves the patient with a balanced asymptomatic lumbar
S161
S162 Spine • Volume 31 • Number 19 Suppl • 2006

Table 1. Pathophysiologic Classification of Kyphosis Table 3. Structural Evaluation of Kyphosis for

Surgical Planning
1. Congenital
Defects of segmentation ● Magnitude of kyphosis
Defects of formation ● Shape of deformity
Fixed ● Number of vertebral segments involved
2. Developmental ● Regional (long segment) or segmental (short segment)
Scheuermann’s kyphosis ● Flexibility (fixed or mobile)
Developmental round back ● Global sagittal balance
Spondylolisthesis
3. Inflammatory
Infective
Pyogenic oping kyphosis than males with progressing age (Figures
Tuberculosis
4. Metabolic 3, 4).4 – 6
Osteoporosis The primary region of the spine dictating sagittal
Osteomalacia alignment is the thoracic spine. This is because the tho-
5. Post-traumatic
6. Tumor racic curve is dictated by the shape of the vertebral bod-
Metastatic ies. The thoracic discs are quite narrow and they add
Neurofibromatosis little to the alignment or flexibility of the thoracic spine.
Other
7. Chondrodystrophic By contrast, the lumbar lordosis, which is the other ma-
Achondroplastic dwarf jor component of sagittal alignment, can easily be con-
Mucopolysaccharidoses sidered a secondary curve because at least early on, it is
Spondylo-epiphyseal dysplasia
8. Latrogenic flexible. Increased flexibility due to large disc spaces al-
Post laminectomy lows mobility in both flexion and extension to compen-
Post irradiation sate for the more inflexible sagittal contours in the
thoracic spine. However, if one is to believe Madam Du-
val-Beapere’s theory, both lumbar lordosis and thoracic
hyperlordosis. Most important, the flexibility of the ky-
phosis must be assessed, namely, is the kyphosis fixed or
mobile? This distinction will determine the surgical tech-
niques used (Table 3).
Evaluation of Kyphosis
When evaluating the spine for sagittal alignment, the C7
plumbline (C7PL) should fall through the posterior su-
perior corner of S1 or between the posterior superior
corner of S1 and the hip joints (Figure 1). This narrow
range of “acceptability” for the alignment of the C7PL
still allows for an infinite combination of cervical and
lumbar lordosis and thoracic kyphosis to achieve bal-
ance. Madame Duval-Beapere has suggested that fixed
pelvic parameters: pelvic incidence (PI) is the primary
determinant of appropriate thoracic kyphosis and lum-
bar lordosis for each person (Figure 2). Values for “nor-
mal” thoracic and thoracolumbar sagittal alignment
have been detailed in the literature by numerous authors3
(Table 4). The normal range for thoracic kyphosis is 10°
to 40° and the normal range for lumbar lordosis is 30° to
80°. These values vary considerably with age, gender,
and pathologic conditions. When considering the popu-
lation in general, increasing age is positively correlated
with increasing thoracic kyphosis. This is true for both
males and females with females more prone to a devel-

Table 2. Morphological Classification of Kyphosis

● Pure kyphosis
● Kyphosis with vertebral subluxation
● Angular kyphoscoliosis - severe types
Figure 1. C7 plumbline (C7PL). Reproduced with permission from
Kyphosis with rotatory subluxation
Hairpin kyphosis O’Brien MF, Kuklo TR, Blanke KM, et al, eds. SDSG Radiographic
Measurement Manual. Memphis: Medtronic Sofamor Danek, 2005:89.
 Thoracic and Thoracolumbar Kyphosis • Macagno and O’Brien S163

Figure 3. Degree of kyphosis in women, by age. Adapted with

permission from Frymoyer JW, ed. The Adult Spine, 2nd ed. Phil-
adelphia: Lippincott-Raven, 1997:1538.

This is followed by an assessment of the range of motion

Figure 2. Pelvic incidence (PI). Reproduced with permission
from O’Brien MF, Kuklo TR, Blanke KM, et al, eds. SDSG Ra-
diographic Measurement Manual. Memphis: Medtronic Sofa-
mor Danek, 2005:97.
kyphosis are influenced or perhaps determined by intrin-
sic fixed pelvic parameters, i.e., PI.7
When evaluating kyphotic deformities, it is important
to understand both the radiographic investigations and
the clinic examination. Identification of a kyphotic align-
ment on radiographs does not necessarily imply the need
for treatment, either operative or nonoperative. The clin-
ical examination of a patient with sagittal malalignment
begins with visual assessment of the coronal and the sag-
ittal alignment of the patient’s occiput over the pelvis.
and flexibility of the cervical, thoracic, and lumbar spine.
Each region of the spine is assessed for its contribution to
either the fixed or the flexible sagittal plane malalign-
ment. This assessment may be assisted by evaluating the
position, shape, and flexibility of the spine in the stand-
ing, seated, and supine positions.
Although it seems intuitive, a distinction must be
made between sagittal malalignment secondary to iatro-
genic flatback phenomenon (Figure 5a, b), and regional
kyphotic malalignments (Figure 5c, d). A patient with a
flatback syndrome (Figure 5a, b) has poor global sagittal
alignment (positive sagittal balance). This is most com-
monly due to flattening of the lumbar lordosis or lumbar
kyphosis. In contradistinction, a patient with a signifi-
cant thoracic kyphosis may remain flexible and in rea-
sonably acceptable global sagittal alignment (Figure 5c,
d). Either patient may be symptomatic or asymptomatic.
Not all sagittal malalignment has the same etiology or
treatment. It is also important to assess the neurologic
status in patients with kyphosis. Patients with sharp an-
gular kyphosis or large magnitude kyphosis may have

Table 4. Sagittal Alignment

Stagnara et al15 Bernhardt and Jackson and
(n ⫽ 100; Bridwell3 (n ⫽ 102; McManus16
ages 20–29) ages 4.6–29.8) (n ⫽ 100; ages 20–63)

T1–12 — 41 42
T1–2 — ⫹1 —
T2–T3 — ⫹3 —
T3–T4 — ⫹3.5 —
T4–T5 ⫹5 ⫹5 —
T5–T6 ⫹5 ⫹5 —
T6–T7 ⫹6 ⫹5 —
T7–T8 ⫹5 ⫹5 —
T8–T9 ⫹4 ⫹4 —
T9–T10 ⫹3 ⫹3 —
T10–T11 ⫹2 ⫹3 —
T11–T12 ⫹2 ⫹2.5 —
Figure 4. Degree of kyphosis in men by age. Adapted with per-
T12–L1 ⫹1 ⫹1 —
L1–L2 ⫺2 ⫺4 ⫺1.7 mission from Frymoyer JW, ed. The Adult Spine, 2nd ed. Philadel-
phia: Lippincott-Raven, 1997:1538.
S164 Spine • Volume 31 • Number 19 Suppl • 2006
Figure 5. (A and B) Iatrogenic postfusion flatback phenomenon. (C and D) Regional kyphosis (Adult Scheuermann’s).
associated neurologic compression resulting in either
myelopathy or radiculopathy or both.
The radiographic investigation of patients with ky-
phosis begins with standing AP and lateral 14 ⫻ 36 inch
radiographs. These films should detail the position of the
occiput in relation to the pelvis, hips, and proximal fe-
murs. The radiographs should be taken with the patient’s
knees in full extension. This position will exacerbate the
positive sagittal balance of fixed global sagittal malalign-
ments. Plain myelograms and CT myelograms are very
helpful in defining the intimate association between the
osseous structures and the neural elements. When these
two studies are combined with MRIs, a detailed under-
standing of the neural anatomy in relation to the osseous
anatomy can be achieved. This is very important when
considering more aggressive surgical interventions, such
as osteotomies. Discograms are useful for identifying
symptomatic levels adjacent to a planned surgery. Al-
though discograms are controversial, in an appropriate
patient and with a skilled discographer, this study may
provide useful information when attempting to limit the
extent of a fusion. Maintaining several distal mobile seg-
ments will allow dynamic balancing of the spine over the
pelvis.
Treatment Options
Initial treatment options for all kyphotic problems, save
those with significant neurologic deficits, are nonsurgi-
cal. Exercise and aerobic conditioning programs may be
useful. This may be supplemented with nonsteroidal an-
ti-inflammatory regimens and muscle relaxers. Although
narcotics and other analgesic medicines may be helpful
when beginning the program, prolonged use is likely to
be counterproductive. These nonoperative programs will
likely be incompletely effective. Patients with smaller
flexible sagittal deformities are more likely to gain relief
from these nonoperative measures than are those pa-
tients with large magnitude fixed deformities that result
in significant positive sagittal malalignment. In the adult
population and in those patients with a fixed sagittal
deformity, bracing is not effective.
When nonoperative measures have failed, surgery
may be considered. The operative treatment of sagittal
plane deformities is a significant undertaking. This is
particularly true when surgeries requiring multiple os-
teotomies are involved. These procedures expose the
neural elements to mechanical and vascular trauma. The
patient is exposed to significant blood loss, large fluid
shifts, metabolic and multiorgan stress, and severe pain.
The pain management required after these surgeries is
not benign, especially in fragile adults who may already
be heavily addicted to opioid medications after years of
“pain management.” The surgeon must accurately ascer-
tain the general medical condition and risk for the pa-
tient. It is also important to have a clear understanding of
both the objective and the subjective neurologic com-
plaints of the patient. Kyphosis is often associated with
neurologic deficits. These deficits may be subtle and dif-
ficult to elicit in debilitated patients. This may result in
underestimating a “sick spinal cord.” The compromised
spinal cord may only become apparent intraoperatively
or after surgery when overt neurologic deficits develop.
Treatment of large kyphotic deformities, particularly
those with sharp segmental malalignments, are particu-
larly dangerous. The spinal cord is at risk from mechan-
ical stresses placed on it due to the angular deformity
itself, intraoperative manipulation, and altered intrapa-
renchymal or extraparenchymal spinal cord blood flow.
This alteration in blood flow may result from either di-
rect compression resulting in occlusion of vessels or from
vascular spasm due to stretching and manipulation of the
spinal cord. Patients must be evaluated for cardiac and
pulmonary pathologies. The patient’s nutritional status
is also important to assess. Other comorbidities must be
assessed, such as smoking, inflammatory diseases, diabe-
tes, and obesity.
 Thoracic and Thoracolumbar Kyphosis • Macagno and O’Brien S165
The surgical techniques to treat kyphosis are divided
into two main categories: anterior and posterior proce-
dures. Anterior procedures are typically not the primary
procedure. Anterior procedures are usually adjunctive pro-
cedures for spinal release, decompression of the neural ele-
ments, and resection of vertebral bodies. Anterior proce-
dures are useful as part of a pretraction spinal release or to
mobilize the spine during a same-day two-stage procedure
to allow definitive realignment posteriorly. Post-release
traction takes advantage of the viscoelastic properties of the
spinal column and may be very useful in achieving signifi-
cant correction over time. Occasionally, an anterior proce-
dure may be the primary procedure. If the kyphotic pathol-
ogy is focal/segmental, and can be corrected by resection of
the anterior and middle column followed by distraction
and anterior reconstruction, then a posterior procedure
may be avoided. Posterior procedures are required for long
deformities. The posterior approach is extensile from the
occiput to the pelvis. Posterior approaches permit treat-
ment of both regional/global and focal/segmental deformi-
ties. Using osteotomy techniques, the posterior elements,
pedicles, and vertebral bodies can be accessed to mobilize
and reposition the spine. The posterior approach provides
access for both anterior and posterior column resection,
extensile fusions, and provides numerous vertebral fixation
options using hooks, screws, and wires.
Radiographic assessment of the curve is the next most
important step in planning surgery. There are four main
components to this evaluation: curve magnitude, loca-
tion, type, and flexibility. Curve magnitude is the most
obvious parameter when assessing kyphotic deformities
and sometimes the most clinically apparent. Except for
the fact that there is often a positive linear correlation
with increasing stiffness as curve magnitude increases,
curve magnitude is probably the least important compo-
nent of the deformity for determining surgical interven-
tion. Curve location may carry with it some implications
for surgery treatment. This is especially true when curves
are located at transition segments of the spine: the cervi-
cal-thoracic, thoracolumbar, and lumbosacral junctions.
Kyphotic deformities located at these transition zones
may require crossing from the primary region of defor-
mity into the adjacent functional zone. This may result in
altered function and mobility and require application of
different surgical techniques. The type of kyphosis is im-
portant in assessing surgical treatment options. There are
two types, global or regional versus focal or segmental.
Global or regional curves will require extensive mobili-
zation and instrumentation to provide balanced correc-
tion. These deformities require significant surgeries and
are often associated with perioperative and postopera-
tive morbidity. Focal or segmental kyphosis resulting
from posttraumatic malalignment or congenital condi-
tions often requires shorter, more focused surgeries.
The last and perhaps most important radiographic as-
sessment to be made is that of spinal flexibility through the
kyphotic region. The flexibility of the deformity will define
the surgical techniques that are most appropriate for cor-
rection. Flexible curves such as those found in Scheuer-
mann’s kyphosis can be treated with cantilever correction
maneuvers often without any osteotomy procedures. Rigid
curves will require osteotomies or vertebral column resec-
tion to achieve correction. The prototypic pathology in this
later group is a congenital kyphosis resulting in a sharp
angular deformity over one or two levels.
Osteotomies
The development of osteotomy techniques has advanced
our ability to treat spinal deformities.8 The shift away
from simple compression/distraction or cantilever ma-
neuvers as a means of realigning the spine in favor of
vertebral column osteotomies and resections with poste-
rior column shortening has been an important philo-
sophical and practical paradigm shift away from com-
bined anterior-posterior procedures9,10 in the treatment
of these sagittal plane deformities. Lesser osteotomy/
resection techniques, such as aggressive facetectomy
combined with removal of intraspinous ligaments or
very aggressive facetectomies and posterior column re-
sections as described by Ponte, may be useful. Kyphotic
deformities that are rigid with large magnitude deformi-
ties may require more aggressive osteotomy techniques,
such as pedicle subtraction osteotomies or vertebral col-
umn resection. When considering the pros and the cons
of these procedures, one must balance the risk versus
benefit profile for the patient.
The simplest osteotomy/resection technique available
is aggressive facetectomies. This can be performed with
minimal blood loss. It does not put the dura or neural
elements at risk and may be performed at multiple levels.
The limitations of the technique, however, are that it
must be performed at multiple levels, each level provid-
ing only small amounts of correction.
Considerable discussion and confusion have circu-
lated recently regarding the differences between, and the
applicability of, two of the most useful posterior osteot-
omy techniques that we currently have at our disposal.
The Smith-Petersen and the Ponte osteotomy are similar
but have certain differences that make them unique in
both their application and their execution.
The Smith-Petersen osteotomy (SPO) was described
as a monosegmental chevron or “V”-shaped osteotomy
for the lumbar spine in 1945 (Figure 6).11 It is described
as a posterior element resection with osteoclasis of the
anterior and middle column. The technique as it was
originally described results in lengthening of the anterior
column and shortening of the posterior column with the
middle column functioning as a pivot point. This maneu-
ver has been associated a number of severe complica-
tions, including aortic rupture, cauda equine syndrome,
paraplegia, and superior mesenteric artery syndrome.
This maneuver also results in an anterior column defect
occasionally requiring reconstruction with anterior col-
umn support. This is a “true” osteotomy as it is described
for use in patients who are fused over the segments being
S166 Spine • Volume 31 • Number 19 Suppl • 2006

Figure 6. Smith-Petersen osteotomy. Reproduced with permission

from Wiggins GC, et al. Management of iatrogenic flat-back syn-
drome. Neurosurg Focus (J Neurosurg AANS) 2003;15:5.

operated on. The effectiveness of this technique is much

improved when it is applied to those patients who do not
have an anterior column fusion. The technique is exe-
cuted by resecting a “V”-shaped portion of the posterior
elements (lamina and spinous process) and fusion mass
between adjacent pedicles. One millimeter of resection
will equate to approximately 1° of lordosis once the os-
teotomy is closed.
The Ponte osteotomy (PO), described by Alberto Ponte
in 198712,13, was described as a multilevel thoracic proce-
dure to treat flexible thoracic kyphosis (Figure 7). It is exe-
cuted by undertaking an aggressive resection of the unfused
facet joints, lamina, intraspinous ligaments, and ligamen-
tum flavum at each level. Since the “osteotomy” is applied
to the unfused spine, it could be argued that it is not an
osteotomy in the true sense of the term. However, since it
does require significant and specific osseous resection to be
effective, the fused versus unfused status of the spinal seg-
ment is probably irrelevant. The PO resection can be nar-
row, amounting to an aggressive facetectomy or as radical
as a complete resection of the posterior elements from pedi-
cle to pedicle at each level. Since the technique is performed
on the unfused spine, there is a mobile disc at each level.
Another difference between the SPO and the PO is that it is
performed at multiple levels. This spreads the angular cor-
rection and anterior column translation, if any, over multi-
ple levels. The IAR moves into the anterior column when
using this technique, resulting in an overall “closing
wedge” effect. This differs from the SPO’s anterior column
“opening wedge” and posterior column “closing wedge”
effect. In addition, the anterior column remains supported
by its undisturbed physiologic structures (discs, liga-
ments), leaving a stable spine after posterior column re-
construction. Additional anterior column procedures are
unnecessary.
The Ponte osteotomy has pros and cons similar to the
aggressive facet resection technique previously men-
tioned. The pros are that the technique is simple and may
be performed at multiple levels. The osteotomies may be
Figure 7. Ponte osteotomy. Reproduced with permission from
Harry L. Shufflebarger, MD.
small or taken from pedicle to pedicle to provide signif-
icant multisegmental correction. The downside of this
technique is that multiple osteotomies will be required to
achieve significant correction since a Ponte osteotomy
may only provide a few degrees of correction per level. In
addition, the technique requires a mobile anterior and
middle column to be useful and may be associated with
significant epidural bleeding. Careful attention to surgi-
cal details and meticulous hemostasis is important.
While working best on long flexible kyphosis, even rela-
tively stiff curves may be effectively treated with this tech-
nique. The PO may also be useful when performed above
and below more aggressive osteotomies to provide a har-
monious transition between areas of maximum and min-
imum kyphosis. PO can also be added as an after thought
to add a few more degrees of correction above or below
a major deformity correction (Case 2).
Multicolumn (anterior, middle, posterior column) resec-
tions, such as pedicle subtraction osteotomy and vertebral
column resection, represent the next level both in technical
difficulty and usefulness for treating large kyphotic defor-
mities. These techniques will be discussed in detail by Dr.
Bridwell elsewhere in this publication. Suffice it to say that
these techniques rely on resection of two or more columns
of the spine. The benefits of these techniques are that sig-
nificant correction can be achieved at a single level. On the
 Thoracic and Thoracolumbar Kyphosis • Macagno and O’Brien S167
other hand, these techniques are often associated with sig-
nificant bleeding. In addition, there is increased risk for
neural injury because of exposure and manipulation of the
neural elements.14 These osteotomies are useful but techni-
cally demanding to perform (Case 3).
Fixation for Kyphotic Deformities
Nonsegmental or nonrigid fixation, such as sublaminar
wires and hooks, may be useful in smaller, more flexible
deformities. However, as increasingly more destabilizing
osteotomies or resection techniques are used in stiffer defor-
mities, maximum fixation is required. The author’s prefer-
ence is for bilateral, segmental, pedicle screw fixation
whenever possible. This spreads the forces applied to the
construct and subsequently to the spine, over the most seg-
ments. It achieves the largest cross-sectional area of engage-
ment of the osseous anatomy and fixes to all three columns
of the spine. This also provides for maximum intraopera-
tive control of the osteotomy segments and allows for max-
imum versatility in achieving reduction. Having bilateral
screws at every level in a relatively flexible Scheuermann’s
kyphosis may seem excessive; however, this construct does
provide maximum engagement of the osseous anatomy in-
creasing stability. It also allows segmental and evenly dis-
tributed compression forces to be applied across each seg-
ment, thus maximizing correction forces. On the other
hand, for pedicle subtraction osteotomies and vertebral col-
umn resections, bilateral, segmental fixation is mandatory.
This facilitates control of the spinal segments intraopera-
tively and then provides maximum stabilization once the
vertebral column is reconstructed. For these more aggres-
sive resections, at least four pedicle screw fixation points
above and below the osteotomy are required. If the anat-
omy and the goals of surgery permit, I prefer 6 to 8 fixation
points above and below large or multiple osteotomies for
large magnitude deformities. Low lumbar osteotomies will
likely require at least temporary if not permanent fixation
to the sacropelvic unit. This could include a combination of
S1, alar, and iliac screws to provide secure distal fixation. If
osteotomies are performed through a previously fused re-
gion of the spine, the entire fused region should be instru-
mented. This will provide maximum fixation in the spinal
segment being treated, which is often osteopenic.
Conclusion
There are many options available for the surgical treat-
ment of kyphotic deformities. As described, they run the
gamut from simple to complex. While the less technically
demanding osteotomy/resection techniques seem simple,
significant realignment of the vertebral column may pose
neurologic risks irregardless of the complexity of the sur-
gical technique. The more aggressive resection tech-
niques are accompanied by high blood loss and the po-
tential for catastrophic neurologic complications. For
this reason, it is mandatory that the surgical technique
chosen should match the requirements of the pathology
and patients metabolic capacities. When 2 different tech-
niques may provide similar results, the less involved tech-
nique should always be used. In this way, the simplest
surgical technique will always be applied to achieve a
balanced spine. However, it is important to acknowledge
that performing inadequate surgery may ultimately
cause more harm to the patient than doing nothing. In its
simplest form the 2 primary tenets of spinal deformity
surgery are: 1) appropriate release or resection of the
deformity to provide adequate mobilization, and 2) pro-
viding sufficient fixation to stabilize the spine and protect
the spinal cord intraoperatively and ultimately to fix the
vertebral column in the reduced position while fusion is
occurring. Appropriate exposure to and experience with
these techniques will allow the surgeon to treat a variety
of simple and complex deformities. However, even in the
hands of experienced surgeons, these techniques may re-
sult in significant complications. Both the surgeon and
the patient are well advised to consider their options
carefully before surgery.
Case 1
Case 1 is 57-year-old woman with a history of Scheuer-
mann’s kyphosis. The patient has lived with her spinal
deformity since adolescence. In the 5 years before the
patient’s presentation to clinic, she has experienced in-
creasing back pain and slowly increasing deformity. Ra-
diographic evaluation shows the typical thoracolumbar-
lumbar scoliosis that often accompanies these primarily
kyphotic deformities (A, B). Postoperative radiographs
show good coronal and sagittal alignment (C, D). It is
important not to underestimate the small coronal plain
deformity that is often associated with these curves. In-
strumentation must include both the sagittal and coronal
deformity. Postoperative junctional kyphosis can often
be a problem after correction of these deformities. This
junctional problem may occur either at the proximal or
distal ends of the construct. While this patient’s align-
ment is currently excellent, the author is concerned that
there could be proximal falloff above the T3 fixation.
Perhaps in this patient fixation to include T1 or T2
would have been prudent. No specific preoperative risk
factors have been identified that definitively lead to the
development of either proximal or distal junctional post-
operative kyphosis. However, a soft correlation with
correction of the original sagittal deformity by more than
50% has been implicated in the development of junc-
tional kyphosis in long constructs for Scheuermann’s dis-
ease. Also, excessive straightening of the upper thoracic
spine in the sagittal plane may result in proximal junc-
tional kyphosis. Distal junctional kyphosis may occur
when fixation does not include the first lordotic disc be-
low the deformity. The osteo-ligamentous tether that
spans the transition area between instrumented and non-
instrumented spine should be left undisturbed if possible.
Case 2
Case 2 is a 23-year-old, engaging, intelligent, young man
with severe cerebral palsy. He is very active in the commu-
nity and highly mobile in his electric wheelchair. The pa-
tient has some lower extremity motion, which is nonfunc-
S168 Spine • Volume 31 • Number 19 Suppl • 2006
Case 1.
tional for ambulation but is useful for positioning himself in
his wheelchair. The patient’s primary complaints are in-
creasing thoracic back pain and neck pain. Most impor-
tantly, the patient’s activities of daily living have suffered
significantly because of his inability to maintain his occiput,
cervical, and thoracic spine in an upright position. This has
resulted in an increasing number of collisions with immo-
bile objects and unsuspecting pedestrians. This has resulted
in a progressive decrease in function that is unacceptable.
The patient’s lower extremity neurologic examination is
stable. Clinical photographs show the patient’s spinal posi-
tion (A). With extreme effort and discomfort, the patient is
able to raise his head but is only able to maintain this posi-
tion for short periods of time. The patient also complains of
difficulty breathing and eating because of the chest-on-chest
deformity. Radiographs document the patient’s spinal
alignment (B, C). The lateral shows the magnitude of the
thoracic deformity. The patient was treated with a combi-
nation of two apical pedicle subtraction osteotomies, one at
T7 and one at T9. Additional correction was achieved by
Case 2.
performing Ponte osteotomies at the levels above and be-
low. Excellent coronal and sagittal alignment was achieved
(D, E).
Case 3
Case 3 is a 37-year-old woman with neurofibromatosis and
a progressive thoracic kyphosis, which on presentation was
110° with an associated 64° scoliosis. Although the patient
was ambulatory, she exhibited signs of early myelopathy.
She is hyperreflexic in her lower extremities. She has also
experienced several episodes of mild trauma-induced bowel
and bladder incontinence, which resolved. The patient’s
primary complaints are her progressing neurologic symp-
toms and the painful progressive kyphosis. Clinical pictures
(A, B) show the significant thoracic kyphosis. Preoperative
radiographic evaluation shows the severity of the segmental
thoracic kyphosis between T5 and T8 (C, D). MRI evalua-
tion of the patient shows severe deformation of the spinal
cord through the area of maximum deformity (E, F). The
 Thoracic and Thoracolumbar Kyphosis • Macagno and O’Brien S169

Case 3.

postmyelogram CT scans clearly show the deformity and
the spinal cord compression (G). Surgical intervention was
performed in two stages. Stage 1 included anterior column
resection via thoracotomy with placement of soft graft in
the anterior and middle column followed by partial poste-
rior resection and temporary internal fixation. Stage 2 in-
cluded completion of the vertebral column resection from
the back and reduction of the deformity. Final AP and lat-
eral radiographs after Stage 2 of the procedure show very
acceptable coronal and sagittal correction (H, I). Postoper-
ative clinical pictures show excellent coronal and sagittal
alignment (J, K).
Key Points
● Characteristics of kyphotic deformity important for
presurgical planning are: flexibility of the kyphotic
segment, angularity of the kyphotic segment, length
of the kyphotic segment, and the curve magnitude.
S170 Spine • Volume 31 • Number 19 Suppl • 2006
● There are four posterior osteotomies for sagittal
plane correction: Smith-Petersen osteotomy, Ponte
osteotomy, pedicle subtraction osteotomy, and
vertebral column resection.
● Smith-Petersen and Ponte osteotomies, while
similar, have unique characteristics, which make
them most appropriate for long, sweeping, global
kyphosis, such as Scheuermann’s kyphosis.
● Pedicle subtraction osteotomies and vertebral col-
umn resections are more complicated and potentially
dangerous osteotomies. These are most appropriately
applied to pathologies with sharp angular kyphosis,
anterior fusions, and when maximal visualization
and decompression of the spinal cord is required.
● Segmental vertebral fixation is an integral part of sag-
ittal plane correction using any osteotomy technique.
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