Authors of section

Authors

Han Jo Kim, Marinus de Kleuver, Keith Luk

Executive Editors

Kenneth Cheung, Larry Lenke

General Editor

German Ochoa

Open all credits

Posterior Screws - No direct vertebral body derotation

1. Introduction

The aims of surgery are to:

  • improve the spinal curve
  • improve the three dimensional alignment of the spine
  • prevent progression of the curve in the future
  • improve cosmesis
  • reduce pain
  • optimize pulmonary function
  • maintain neurological integrity

This is achieved by correction of the deformity and creation of a solid arthrodesis of the deformed part of the spine.

For this procedure we will assume a right thoracic and a left lumbar curve.

AIS Lenke 6 Posterior pedicle screws - Aim of surgery

Details on selection of fusion levels can be found here.

2. Approach and preparation

The procedure is performed through a posterior approach with the patient in the prone position. The lengths of the incision will depend on the levels being fused.

AIS Adiopathic adolescent scoliosis Anterior release posterior fixation Lenke 1

3. Pedicle screw insertion

Pedicle screw density would depend on surgeon's preference and preoperative planning. Typically less screws are utilized on smaller and more flexible curves, while more screws are utilized on larger and stiffer curves up to a maximum of segmental screws bilaterally.

Details on pedicle screw insertion.

AIS Lenke 5 Posterior pedicle screws - Pedicle screw insertion

4. Release

Indications for release

Depending on flexibility findings, the release can be carried out only at the apex of the curve, which is usually the stiffest, or the whole length of the instrumented spine.

A release is generally performed if the spine cannot easily align to the rod during surgery. This can be predicted preoperatively based on the bending X-ray. For stiff curves, fulcrum bending X-ray and the traction X-ray under general anaesthesia is the method of choice for determining flexibility.

A soft tissue release can be performed by removal of the interspinous ligaments along with the midline ligamentum flavum of the apical regions of the deformity. If additional release is desired, then formal Posterior Column Osteotomy (PCO) can be performed at the same levels. PCO is also called SPO (Smith-Petersen osteotomy) or Ponte osteotomy. The shaded area to the left outlines the bony resection performed during a PCO.

All posterior releases begin by resecting the inferior aspect of the spinous process, followed by removal of the interspinous ligament utilizing a standard rongeur.

AIS Lenke 1 Posterior pedicle screws - Release

Removal of the 3-5 mm of the inferior aspect of the inferior facet joint is performed at each level of the planned fusion using an osteotome.

The ligamentum flavum is removed with a Kerrison rongeur beginning in the midline and exiting lateral until abutting against the medial aspect of the superior facet. It is important not to penetrate deeply against the dura.

AIS Lenke 1 Posterior pedicle screws - Release

Care should be taken not to tear the dura particularly on the concavity of the curve where the neuro tissues preferentially lie.

A Kerrison rongeur is utilized to remove the most cephalad portion of the superior articular facet exiting out lateral into the neuroforamen. This completes the PCO and is usually repeated at other levels.

Epidural bleeding within the neuroforamen is controlled with hemostatic agents and cottonoid packing.

AIS Lenke 1 Posterior pedicle screws - Release

5. Facet joint fusion

In cases where a PCO has been performed, the facet joint is already removed and this step ("Facet joint fusion") should be omitted.

The inferior articular facet is removed with a osteotome exposing the articular cartilage of the superior articular facet.

AIS Lenke 1 Posterior pedicle screws - Facet joint fusion

Remove the articular cartilage from the superior articular facet using a gouge or a curette.

AIS Lenke 1 Posterior pedicle screws - Facet joint fusion

Insert pieces of bone graft (autograft, allograft, or bone substitute) into the decorticated facet joint for arthrodesis.

These steps are repeated for all the levels on both sides.

AIS Lenke 1 Posterior pedicle screws - Facet joint fusion

6. Rod insertion

Left rod

The left rod is bent to the appropriate thoracic kyphosis as preoperatively planned with the appropriate transition into lordosis of the thoracolumbar junction as necessary.

The amount of thoracic kyphosis bent into the left rod will be based on:

  • curve size
  • curve flexibility
  • number and purchase of bone anchors
  • size and material of the rod utilized.
AIS Lenke 5 Posterior pedicle screws - Rod bending

Starting with the most cranial screw the rod is inserted sequentially into all the screws on the left side of the thoracic and lumbar curve conforming to the two deformities without being locked.

AIS Lenke 5 Posterior pedicle screws - Rod insertion

Rod holders are then applied onto the rod and the rod is rotated 90° counter clockwise around its axis correcting the scoliosis, and restoring the kyphosis in the thoracic spine and the lordosis in the lumbar spine.

This rod-rotation maneuver should be performed slowly and cautiously with careful attention to both the implant-bone interface to avoid pullout, and to the neuromonitoring signals.

AIS Lenke 5 Posterior pedicle screws - Rod rotation

The rod is locked to the most caudal screw to prevent it from rotating back. The other screw heads are kept unlocked.

AIS Lenke 5 Posterior pedicle screws - Rod locking

Right rod

A right side rod is bent to slightly less kyphosis in the thoracic section and less lordosis in the lumbar section compared to the left side.

AIS Lenke 5 Posterior pedicle screws - Rod bending

The right rod is attached to the most cranial thoracic screw in its normal sagittal plane rotation and locked.

AIS Lenke 5 Posterior pedicle screws - Rod insertion

The distal end of the rod is then levered down using a rod holder and sequentially attached to the remaining screws of the thoracic and lumbar curve, starting cranially.

This maneuver will push the thoracic apical rib hump anteriorly, thereby achieving derotation of the apical segments.

AIS Lenke 5 Posterior pedicle screws - Rod application

On attaching the right rod to the lumbar screws on the right side, the lumbar segment will be lifted dorsally and partially derotated.

AIS Lenke 5 Posterior pedicle screws - Derotation

7. Compression and distraction

Compression on the convex side of the lumbar curve

Attention is now returned to the left side. After locking the apical screw to the rod, the convex screws are compressed towards the apical anchor to horizontalize each vertebra and locked in position.

AIS Lenke 5 Posterior pedicle screws - Compression

Compression of the convex side of the thoracic curve

After locking the apical screw to the rod, the convex screws are compressed towards the apical anchor to horizontalize each vertebra and locked in position.

The correction of the thoracic curve stops at the neutral vertebra (usually T12).

AIS Lenke 5 Posterior pedicle screws - Compression

Distraction on the concave side of the lumbar curve

After locking the apical screw to the rod, gentle distraction is applied away from the apex towards the cranial and caudal ends up to the neutral T12 level, locking the screw heads on the way.

Over distraction should be avoided because it will flatten the lumbar lordosis.

AIS Lenke 5 Posterior pedicle screws - Distraction

Distraction on the concave side of the thoracic curve

After locking the apical screw to the rod, gentle distraction is applied away from the apex towards cranial and caudal aspect of the thoracic curve to the neutral (T12) level, locking the screw heads along the way.

Distraction

8. Spinal fusion

Decortication

The laminae and the transverse processes are decorticated with an osteotome.

Care should be taken to always point the osteotome away from the spinal canal.

Alternatively, the decortication may be performed with a powered burr.

AIS Lenke 1 Posterior pedicle screws - Decortication

Bone grafting

Bone graft (allograft, autograft, or bone substitutes) is copiously placed over the entire decorticated area.

AIS Lenke 1 Posterior pedicle screws - Fusion

9. Transverse rod connectors

Transverse connectors are then inserted one at each end of the construct.

AIS Lenke 5 Posterior pedicle screws - Transverse rod connectors

10. Intraoperative imaging

At some point prior to wound closure intraoperative imaging should check:

  • Fusion levels
  • Screw position
  • Overall coronal and sagittal correction and alignment

11. Aftercare following correction of spinal deformity

Immediate postoperative medication

Intravenous antibiotics are administrated for at least 24 hours, depending on hospital protocol. The use of an epidural pain catheter vs. intravenous patient controlled analgesia (PCA) are utilized for acute pain management.

Mobilization

Early mobilization out of bed, is preferably started the day after surgery. Generally a postoperative brace/orthosis is not required.

Postoperative imaging

It is appropriate to obtain upright PA and Lateral xrays of the patient at some point early postoperative either before the patient is discharged from the hospital or at the 1st postoperative visit as an outpatient

Restriction of activities

To allow the bone to heal and form a solid arthrodesis, some restriction of sports activities, especially contact sports, is usually advised for 6 months.

Postoperative complications

Early postoperative complications include:

  • Postoperative wound infection
  • Urinary tract infection
  • Respiratory complications such as pneumonia

Late postoperative complications include:

  • Pseudarthrosis with loss of correction
  • Late deep wound infections
  • "Adding on" which is progression of scoliotic deformity in the non-instrumented spine.
  • Crankshaft phenomenon (progression of scoliotic deformity within the instrumented spine).
  • Implant failure or other implant related complications

In the long term adjacent segment degenerations above and below the instrumented spine may occur.