What is the role of osteotomy and vertebral-column resection in the treatment of kyphosis?

Updated: May 04, 2020
  • Author: R Carter Cassidy, MD; Chief Editor: Jeffrey A Goldstein, MD  more...
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Specific osteotomies are aggressive facetectomies at each level, Smith-Peterson osteotomy, pedicle-subtraction osteotomy, and vertebral-column resection. Two-level osteotomies (eg, pedicle-subtraction osteotomy plus Smith-Peterson osteotomy) for correction of severe kyphosis from ankylosing spondylitis have been described.

Smith-Peterson osteotomy involves wedge-shaped resection of posterior elements from the pedicles of the superior vertebra to those of the inferior vertebra. When closed posteriorly, the spine hinges on the disk space; therefore, an open, mobile disk is crucial to the success of this procedure. The osteotomy can be performed at one or multiple levels, if necessary. This permits significant correction, with approximately 1 mm of resection yielding 1° of lordosis. [10]  Some recommend anterior diskectomy and fusion with Smith-Peterson osteotomy to decrease the pseudarthrosis rate. [20, 46, 47]

Pedicle-subtraction osteotomy involves relatively aggressive resection of a wedge of bone, including posterior elements, the pedicles, and the vertebral body. [48, 49]

Vertebral-column resection entails removal of posterior elements, the vertebral body, and adjacent disk material. Because of the destabilizing effect of this resection, both anterior and posterior fixation are often required. Dreimann et al described the use of posterior vertebral-column resection with 360º osteosynthesis to reduce kyphotic deformity. [50, 51]

As kyphosis becomes notably sharp or focal, increasingly aggressive techniques are required for correction. Cho et al demonstrated that the corrections per segment were 10.7° for Smith-Peterson osteotomy and 31.7° for pedicle-subtraction osteotomy. [52]  Procedures involving the anterior column are usually followed by posterior instrumentation and fusion. Vertebral column resection yielded up to 63% improvement in deformity at 5 years in a medium-term study. [53]

Although having a correction “target” is important in preoperative planning, it is often difficult to assess the correction intraoperatively. The lumbar pelvic angle, a portion of the T1-pelvic angle (TPA), may be useful in this regard and also seems to correlate with patient satisfaction. [54]

Zhong et al investigated the use of a two-level pedicle-subtraction osteotomy in comparison with a one-level pedicle-subtraction osteotomy plus a Smith-Peterson osteotomy for severe kyphosis. [55]  The two-level pedicle-subtraction osteotomy was useful, especially in cases of a fixed kyphosis, such as that due to ankylosing spondylitis.

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