Overview of Spinal Osteotomy

Spinal osteotomy is a term doctors use to describe several operations used to fix abnormalities in the backbone. These operations can be done on both children and adults. The goal of these procedures is to restore the normal curve of the spine, relieve discomfort, and improve the individual’s quality of life.

These operations fall into several distinct types. Posterior column osteotomy (PCO) includes both Ponte osteotomy and Smith-Petersen osteotomy (SPO), and there’s also operations like pedicle subtraction osteotomy (PSO) and vertebral column resection (VSR), which involve removing segments of the spine.

Medical professionals categorize these surgeries from 1 to 6 using the SRS-Schwab classification nomenclature. This system helps doctors communicate how much of the bone or disc needs to be removed during the operation. This helps doctors plan the surgery and patient understand the extent and severity of the operation.

Anatomy and Physiology of Spinal Osteotomy

The success of a type of back surgery known as a posterior approach osteotomy largely depends on comprehensive knowledge of the structure of the spine. This includes understanding the bones, facet joints (the small joints at each segment of the spine that provide stability and help guide motion), discs (the spongy cushions between the bones of the spine), and ligaments (tough bands of tissue that hold the bones together).

This surgery involves viewing the spine in 3D from different angles – front to back (sagittal), side to side (coronal), and top to bottom (axial). This helps the surgeon understand the specific nature of the patient’s spinal problem.

A type of this surgery, called PCO (also known as SPO or Ponte osteotomy), involves removing the facet joints, the lamina (the protective bony roof over the spinal cord), and the posterior ligaments (ligaments towards the back of the spine). The adjustments are made through the disc space, and this procedure aims to lengthen the front part of the spinal column.

The SPO and Ponte osteotomy are classified according to a scale developed by the Scoliosis Research Society and Dr. Frank Schwab, with SPO being a category 1 and Ponte osteotomy being a category 2. Although these terms are often used interchangeably, a Ponte osteotomy specifically refers to a more extensive removal of the back part of the upper spine, typically for a condition known as kyphosis (a forward rounding of the back). The SPO procedure traditionally targets the lower spine, typically for a condition known as ankylosing spondylitis (a type of arthritis that fuses the vertebrae).

Another type of this surgery, called PSO (Pedicle Subtraction Osteotomy), involves removing the bridging bones (pedicles) and sections of the body of the vertebrae in a wedge-like manner. The back part of the spine is then reduced as the final stages of the surgery involve closing and compressing the area from which bone was removed. This falls into the SRS-Schwab category 3. A more extensive PSO would be a category 4.

A VCR procedure represents an extremely thorough removal of the body of the vertebra. A thin layer of bone can be left at the front to protect the major blood vessels. This is classified as an SRS-Schwab category 5 procedure. If the procedure also invades the disc space above or below the vertebra, it is classified as a category 6.

Why do People Need Spinal Osteotomy

PCO, or Ponte osteotomy, is a surgical method used to correct spinal curvature. It can be performed on different sections of the spine to gradually restore its balance. To put it simply, for each section of the spine where the procedure is done, the spine’s curvature can be corrected by about 10 degrees. We can also think of it this way – for every 1 mm of bone that’s removed, the correction will be about 1 degree. This is a particularly good option for conditions like Scheuermann’s kyphosis, which involves a gentle smoothing of a curved spine. Alternatively, it can also be used as an additional procedure to enhance the result in more complex spinal corrections.

For patients with a severely unbalanced and inflexible spine, a technique called PSO, or pedicle subtraction osteotomy, is typically recommended. Now, what’s special about this procedure is that it can result in a substantial roughly 30-degree correction. It’s specifically useful when trying to correct acute spinal deformities and does so by removing the maximum amount of bone. It’s generally reserved for more severe cases.

The most difficult spinal deformities to correct often involve rigid changes in multiple planes, uneven balance, need for removing a semi-vertebra, and sharp angle deformities. For such intricate problems, a technique called VCR, or vertebral column resection, is often the best course of action. It has the potential to correct the spine by substantial 35 to 60 degrees. Clearly, this procedure offers the most significant degree of correction among the common surgical options.

When a Person Should Avoid Spinal Osteotomy

A three-column osteotomy, which is a special type of surgery used to correct serious bone deformities, should only be used for patients with a very rigid and pronounced deformity. In addition to this, the patient’s overall health and daily activities, the condition of their bones, any other medical conditions they might have, and their life quality aims should all be considered before deciding on this kind of surgery.

Equipment used for Spinal Osteotomy

Various types of technology can help ensure that spinal instruments are safely used during surgery. These technologies include c-arm fluoroscopy, which is a type of X-ray used to see the area being treated in real-time; CT image guidance, a type of medical scanning technique; robotic technology; and dynamic surgical guidance that help guide surgeons during the surgery. The choice of technology largely depends on the surgeon’s comfort and preference, as well as cost and availability.

New and improved technologies are coming up, which can make these procedures even safer and more effective. Neuromonitoring, a process to continuously check the brain and nervous system during surgery, is extremely useful. It can be used to monitor maximal expiratory pressure (the maximum pressure a person can exert while exhaling), somatosensory evoked potential (responses from the body’s sensory systems), and spontaneous and triggered EMG (a test measuring muscle response or electrical activity).

Who is needed to perform Spinal Osteotomy?

There’s an ongoing discussion among experts who treat spine conditions about whether one or two specialized spine surgeons should be present during operations to correct spine deformities. However, the main surgeon should always be a specialist in spine surgery, well-practiced in dealing with complex spine problems. It’s equally important to have a dedicated anesthesia team, or a team that puts you to sleep for the procedure. On top of that, there needs to be a team to monitor your brain and nerve activity during the surgery, which includes a technician and a brain doctor, usually working remotely.

For complicated operations in adults, it’s key to work closely with teams that focus on internal medicine or intensive care.

For complicated operations in children, it’s essential to get many professionals involved. These might include the spine surgeon, the child’s main doctor, a diet specialist, a physical therapist, a heart doctor, a lung doctor, a stomach doctor, child life specialists who help children cope with hospital treatments, and social workers, if needed.

Preparing for Spinal Osteotomy

Before an operation, the surgeon needs to plan thoroughly, especially for more difficult and complicated procedures. They often use specialized 3D models to ensure they have a good understanding of the problem. Many studies show that a team approach can improve the results of surgery, reduce the amount of blood lost, and prevent infections. During the surgery, the surgeon may reach a point where they need to pause and plan the next steps. This safety check is important.

From the patient’s point of view, any other health problems should be well-managed before surgery. Meeting with the healthcare team before surgery to make sure every health condition is controlled is very important. This is especially crucial for children, who are more likely to have breathing problems and poor nutrition before surgery. Some children might need special care using a method called gravity traction for an extended period before the operation takes place. It’s very important for patients and their families to have a clear discussion with the doctor about what to expect before, during, and after the surgery.

How is Spinal Osteotomy performed

Let’s break down some major surgical procedures often performed in cases of certain back conditions. These procedures mainly aim to restore the normal alignment of the spine as well as alleviate pain.

Posterior Column Osteotomy

This involves placing special screws (pedicle screws) into your spine. The surgeon then removes the back part of your spine, which includes a bone flap called the lamina and some surrounding tissue. After this, the surgeon may also gently push and compress the space between the rods inserted during surgery to restore the natural curve of your spine. This step will only work if the disc space at the front of your spine is flexible and can tolerate the movement.

Pedicle Subtraction Osteotomy

In this procedure, pedicle screws are also needed but they are fixed into your spine at two points above and below the area where the osteotomy or bone cutting will take place. The surgeon will then remove parts of your vertebrae, or the blocks of bone that make up your spine. This, in turn, exposes more of the surrounding areas. As the surgeon reshapes the spine, a temporary support rod may be put in place if the surgeon observes significant curvature or instability of the spine. The surgeon will then clear away the back of your chosen vertebra, being careful not to damage the tissued-filled sheath in front of it. Finally, the surgeon closes the bone gap and puts the final rod in place. Usually, at least three to four of these rods are put across the bone gap to support the spine.

Vertebral Column Resection

This is a more advanced procedure and involves fixing pedicle screws at least four points above and below the area where your vertebral column, or your spine will be cut. The surgeon removes parts of your vertebrae and careful attention is paid to the blood vessels running along the sides of your spine. Then, the surgeon removes the back parts of your spine and cuts the pedicles, preparing your spine for reshaping. If you are having surgery at the middle part of your spine or thoracic level, the surgeon may need to tie off the exiting nerve root and cut the head of the rib nearby. A temporary rod is placed as soon as the pedicles are removed, and the surgeon will take down the back parts of your vertebrae. The bone gap is then closed and permanent rods are put into place across the spine.

These are complex procedures that are typically done by highly trained spine surgeons using delicate and precise techniques to help enhance your spinal health.

Possible Complications of Spinal Osteotomy

Surgeries to correct spinal deformities in adults can lead to complications in anywhere from 10.5% to 96% of cases. In a prominent study known as the Scoli-RISK-1 Study, it was discovered that right after complex surgery to correct adult scoliosis, or a curved spine, about 22.18% of the patients observed lower strength in their legs. However, six months after the surgery, most of these patients noted an improvement, and by this time, 20.52% were stronger than before their surgery and 10.82% were significantly improved. It is generally understood that the chances of complications increase if a patient needs to have spinal surgery more than once.

A procedure known as a three-column osteotomy, which is used to correct severe spine deformities, has been associated with a high rate of complications because it is a very invasive surgery. One global study reported that 78.0% of patients undergoing this procedure had complications, and 61% had serious complications. Particular risks associated with this surgery include an 11.1% chance of nerve damage in adults and a 40% overall complication rate in children, including an 11.4% chance of nerve damage.

Possible complications can include accidental damage to the spinal cord or nerves, cuts into the dura mater (the outermost layer protecting the brain and spinal cord), infections, or the formation of a pseudomeningocele, which is a collection of spinal fluid under the skin. Complications can also arise from injury to neighboring structures like the lungs, large blood vessels, the abdomen, or lead to conditions such as deep vein thrombosis (blood clots), heart attack, or pneumonia.

After the surgery, doctors must closely watch the patient to make sure the surgical instruments used don’t fail and that the patient doesn’t develop a condition known as proximal junctional kyphosis or proximal junctional failure. These conditions occur when the area of the spine adjacent to the surgery becomes too curved or fails to fully heal.

What Else Should I Know About Spinal Osteotomy?

Advancements in technology have led to an increased dependence on surgeries that approach spinal deformity from the back. Consequently, spinal osteotomy (a surgical procedure to correct spinal deformities) has become a highly effective method to fix these problems through a single approach. This technique is now regularly included in training programs, and more medical professionals are becoming familiar with it. Despite this, it’s essential to remember that these procedures can still have some risks or negative side effects. That’s why a continuous team of healthcare professionals caring for the patient is absolutely crucial.

Frequently asked questions

1. What type of spinal osteotomy procedure do you recommend for my specific condition? 2. What is the SRS-Schwab classification for the procedure you are recommending? 3. What are the potential risks and complications associated with this type of surgery? 4. How will my spine be reshaped and what techniques will be used during the procedure? 5. What is the expected outcome and recovery process after the surgery?

Spinal osteotomy is a type of back surgery that involves making adjustments to the spine to address specific spinal problems. The success of this surgery depends on a comprehensive understanding of the structure of the spine, including the bones, facet joints, discs, and ligaments. Different types of spinal osteotomy procedures, such as PCO, SPO, Ponte osteotomy, PSO, and VCR, involve removing certain parts of the spine to achieve the desired outcome. The specific impact of spinal osteotomy on an individual will depend on their unique spinal condition and the type of procedure performed.

You may need Spinal Osteotomy if you have a very rigid and pronounced bone deformity that cannot be corrected through other methods. Additionally, your overall health, daily activities, bone condition, other medical conditions, and life quality aims will be considered before deciding on this surgery.

A three-column osteotomy should not be performed unless the patient has a severe and inflexible bone deformity. Additionally, factors such as the patient's overall health, daily activities, bone condition, other medical conditions, and life quality goals should all be taken into account before deciding on this surgery.

The recovery time for Spinal Osteotomy can vary depending on the specific procedure and the individual patient. However, it generally takes several weeks to several months for patients to fully recover from Spinal Osteotomy. During this time, patients may need to wear a brace, undergo physical therapy, and follow a rehabilitation program to regain strength and mobility in the spine.

To prepare for Spinal Osteotomy, the patient should meet with the healthcare team before surgery to ensure that all health conditions are controlled. This is especially important for children who may need special care using gravity traction before the operation. It is also important for the patient and their family to have a clear discussion with the doctor about what to expect before, during, and after the surgery.

The complications of Spinal Osteotomy include lower strength in the legs, nerve damage, damage to the spinal cord or nerves, cuts into the dura mater, infections, pseudomeningocele (collection of spinal fluid under the skin), injury to neighboring structures, deep vein thrombosis, heart attack, pneumonia, failure of surgical instruments, and proximal junctional kyphosis or failure.

The text does not provide specific symptoms that would require spinal osteotomy. However, spinal osteotomy is generally recommended for patients with severely unbalanced and inflexible spines, acute spinal deformities, rigid changes in multiple planes, uneven balance, the need for removing a semi-vertebra, and sharp angle deformities.

There is no specific information provided in the given text about the safety of spinal osteotomy in pregnancy. It is recommended to consult with a healthcare professional for personalized advice regarding the safety of any surgical procedure during pregnancy.

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