Osteotomies for Adult Deformity: Surgical Techniques

Spinal osteotomies play an important role in the surgical treatment of deformity. The Smith-Petersen osteotomy (SPO), the pedicle subtraction osteotomy (PSO), and the posterior vertebral column resection (pVCR) are the 3 most commonly performed procedures. The SPO is useful for longer sweeping types of kyphotic deformities, whereas multiple SPOs are performed, and there is some degree of flexibility in the disk space. SPOs typically produce 10° of correction per level. There are very few reported neurologic complications with the SPO. The PSO is performed in the lumbar spine and indicated in kyphotic deformities that are rigid and angular with increased sagittal imbalance (>10 cm). PSOs typically produce a correction of 30°. The rate of reported permanent neurologic complications is 3%. pVCRs are indicated for rigid, angular deformities in the thoracic spine and reported corrections are in the 50-60° range. pVCR is the most complex procedure and has several reported neurologic complications. The use of intraoperative neurologic monitoring and surgical intervention in response to the monitoring changes prevented permanent neurologic injury in the largest reported series.