CHAPTER
Christopher L. Hamill
90
Sagittal Imbalance
INTRODUCTION
Sagittal imbalance presents with typical clinical manifestations
that result from the loss of the normal harmonious alignment
of the spine. The presentation can encompass a number of
clinical complaints but primarily involves the loss of the ability
to stand in the upright position. This typically leads to fatigue
of the lumbar extensor musculature due to the biomechanical
disadvantage of the lumbar extensors resulting in low back
pain. As a result of the pitched-forward posture, in an attempt
to maintain forward gaze and center the head over the pelvis,
the patient stands in a characteristic posture with a maximally
retroverted pelvis and flexed knees. The deformity can be fixed
or flexible, which determines the treatment algorithm. There
are several common clinical scenarios of sagittal imbalance:
Patients with lumbar scoliosis who have had a previous Har-
rington instrumentation, usually down to the L4 or L5 level,
which carries significant risk of premature disc degenera-
tion, which in turn leads to loss of the ability to hyperextend
the remaining mobile segments and therefore to compen-
sate for the kyphosis over the instrumented levels;
Patients with prior thoracolumbar fractures, which have
healed in relative kyphosis, causing sagittal imbalance;
Iatrogenic causes of sagittal imbalance such as a multilevel
laminectomy or lumbar arthrodesis in hypolordosis; and
Patients with ankylosing spondylitis who may develop global
sagittal imbalance due to development lumbar hypolordosis
and cervicothoracic kyphosis.
There are several surgical techniques available for the cor-
rection of sagittal imbalance. The most common methods of
treatment include a spinal fusion with instrumentation com-
bined with a single or multiple Smith-Petersen osteotomies
(SPOs), a pedicle subtraction osteotomy (PSO), or a vertebral
column resection (VCR). Although these operative procedures
are technically demanding and fraught with potential compli-
cation, with meticulous planning and execution outcomes in
properly selected patients can be excellent with significant
improvements in the quality of life.
CLINICAL EVALUATION
A careful history and physical examination of the patients with
sagittal imbalance will help establish the diagnosis and establish
a treatment plan. Patients should be examined, first standing in
a natural compensated and then uncompensated states.
938
LWBK836_Ch90_p938-947.indd 938
Peter D. Angevine
Keith H. Bridwell
Typically the loss of lumbar lordosis results in forward inclina-
tion of the trunk. Patients will try to compensate through the
remaining mobile spinal segments. These areas of the cervico-
thoracic and lower lumbar regions can also become pain gen-
erators. The physical examination demonstrates the flattening
of the lumbar spine. Careful examination of each general region
for deformity may reveal a focal or a gradual deformity. Patients,
in an effort to maintain horizontal gaze, will also flex their knees
and hyperextend the mobile spine, especially the cervical spine.
This can lead to premature degeneration of the mobile seg-
ments. Biomechanical studies have demonstrated that increased
paraspinal muscle forces are required to maintain an erect pos-
ture in the face of decreased lumbar lordosis.
It is also important to examine patients in the uncompen-
sated state to fully appreciate the magnitude of deformity. This
usually can be accomplished with full extension of the knees.
The sagittal imbalance may be fixed or flexible. To determine
the flexibility state, patients should be placed supine and prone
on the examination table. In some cases, patients may need to
be maintained supine to allow for muscle relaxation and maxi-
mal spontaneous correction. Hip flexion contractures and
abnormal pelvic tilt (PT) may also be found in patients with
sagittal imbalance. The PT in the sagittal plane may be due to
either anterior or posterior inclination. Patients with anterior
PT typically present with decreased patient satisfaction even
with the restoration of lumbar lordosis secondary to persistent
stooping.9
The standard neurological examination of both the cervical
and thoracic myotomes should be performed whenever exam-
ining a patient with sagittal imbalance. Careful examination for
symmetry and muscle atrophy in these patients is crucial. The
sagittally imbalanced patient usually has had multiple operative
procedures, and the identification of any obviously preexisting
neurological deficit prior to an operative procedure is manda-
tory. True nerve root tension signs, that is, ipsilateral or crossed
straight leg raise, are unusual in this patient population. On
questioning, however, a significant proportion of these patients
will admit to symptoms of lumbar spinal stenosis.
NORMAL SAGITTAL ALIGNMENT
The understanding of what constitutes normal sagittal balance
is a prerequisite to understanding the pathological state of sag-
ittal imbalance. Efficient, pain-free bipedal posture and ambu-
lation depends on the transmission of force through the
skeletal structure. Neutral spinal balance centers the weight of
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 Chapter 90 Sagittal Imbalance 939

the head and posterior over the pelvis, which in turn transmits
the force of the femoral heads via the acetabula. Although
there is not a single normal sagittal spinal contour, research
has demonstrated that there are relatively some conserved rela-
tionships between sagittal curves among patients without back
pain.1 Bernhard and Bridwell1 found that a well-balanced spine,
in general, has between 10 and 30 more lumbar lordosis than
thoracic kyphosis. There is also evidence to suggest that sagittal
alignment changes over time as the intervertebral disc and
facet degeneration leads to loss of lumbar lordosis and increas-
ing thoracic kyphosis. This process may be associated with the
progression of sagittal imbalance.6

RADIOGRAPHIC EVALUATION
The single most important study for the evaluation of sagittal
imbalance is a properly exposed lateral long-cassette (36-in.)
radiograph of the entire spine. The field of view should include
the entire spine and the base of the occiput and proximal
femurs. The optimal patient stance for obtaining these antero-
posterior (AP) and lateral radiographs has been established by
Horton et al.8 A comparison was made between three different
lateral radiographs with arm positioning varying between
straight out, partially flexed, and fully flexed in the clavicle
position. They found no view to be perfect. The clavicle posi-
tion gave superior visualization of T2, T12, and L5-S1 compared
with the 90 position. The clavicle position was superior to the
partially flexed position for visualizing T12 and for the overall
rating. They also found the clavicle position did provide the
best visualization of key landmarks without external support,
which may affect the sagittal vertical axis. It is our practice to
use the clavicle position if patients can maintain their balance
in this position. This position entails fully flexed elbows with
the hands in a relaxed fist. This allows for the proximal inter-
phalangeal joints to be placed carefully into the supraclavicular
fossa; the feet should be kept at shoulders width, knees in
extension, and hips extended.
The most commonly used radiographic reference points for
determining overall sagittal balance are the centrum of the C7
body and the posterior superior corner of the sacrum. The hori-
zontal distance between the vertical plumb line extending from
the C7 body and the posterior superior sacral corner is mea-
sured. The body of C2 may also be used as the origin of the verti-
cal plumb line, but it may be more difficult than C7 to visualize
on long-cassette radiographs. By definition, radiographic posi-
tive sagittal balance occurs when the C7 plumb line falls anterior
to the sacral reference point. If the plumb line is posterior to the
sacral reference point, the sagittal balance is negative.
The sacral pelvic alignment is an important aspect of sagittal
plane deformity, both for understanding its magnitude and for
planning any surgical correction. The pelvic incidence (PI) is
an anatomically fixed measurement for each patient. It is
defined as the angle between the line from the center of the
femoral heads to the midpoint of the proximal sacral end plate
and the perpendicular bisector of the sacral end plate that
extends dorsocaudally.10 While the PI is constant in each indi-
vidual, it is the sum of two variable component angles, the
sacral slope (SS) and the PT. The PT is the angle between a
vertical reference line through the centrum of the femoral
head and the line from the center of the femoral head to the
midpoint of the proximal sacral end plate. The SS is the angle
Figure 90.1. Pelvic incidence (PI)  pelvic tilt (PT)  sacral slope
(SS). The PI is the angle of pain when perpendiculars are drawn to
the center of the sacrum and the femoral head.
between the proximal sacral end plate and a horizontal refer-
ence line. As these angles sum to PI (PI  SS  PT), they are
obviously inversely related (Fig. 90.1). The use of sacropelvic
parameters has added to the clinicians understanding of the
magnitude of sagittal misalignment. A greater PI necessitates
more lumbar lordosis to maintain sagittal balance. As the lum-
bar lordosis decreases, the patient may rotate the pelvis posteri-
orly to maintain overall sagittal balance; this effectively extends
the hips while increasing the PT and decreasing the SS. The
limit of this compensatory mechanism is reached when the hips
are maximally extended within the acetabula. Further compen-
sation is achieved with knee flexion. The result is a typical pos-
ture of a severely sagittally imbalanced patient who stands with
flexed knees and hips that appear to be flexed but are actually
maximally extended (Fig. 90.2A through 90.2D).
Supine AP and lateral radiographs can provide additional
information about the flexibility of the deformity. Analysis of
the spinal alignment in the local regions can be assessed on the
more coned-down views of the spine. Particular attention
should be paid to the flexibility in the areas of maximal defor-
mity as demonstrated by the changes in the intervertebral disc
height and angulation. Flexibility radiographs also may help
distinguish the presence of nonunion and aid in preoperative
planning. It is important to remember that clinical and radio-
graphic flexibility studies do not typically demonstrate the max-
imal spontaneous correction possible. However, careful preop-
erative flexibility evaluation will indeed help the surgeon to
determine the rigidity of the deformity and whether an osteot-
omy will be required to achieve adequate correction.

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 940 Section VIII Adult Spinal Deformity

A B C

Figure 90.2. (A through D) A 72-year-old woman with typical stance of flatback

deformity. Notice the slight decompensation to the right. The flexed knee and hip to
D
allow for forward gaze and abdominal crease.

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 Chapter 90 Sagittal Imbalance 941

TABLE 90.1 Categories of Sagittal Imbalance

Sagittal Imbalance Type Global Sagittal Balance Global Coronal Balance Treatment Options
I Maintained Maintained Smith-Petersen
osteotomies, possibly
pedicle subtraction
osteotomy (PSO)
II Disrupted Maintained PSO, vertebral column
resection (VCR)
III Disrupted Disrupted VCR

CLASSIFICATION type I sagittal imbalance. In these cases, there is regional hyper-

Sagittal imbalance has historically been classified as type I, type
II, and type III deformities (Table 90.1).4 Type I imbalance has
a portion of the spine in the hyperkyphotic state, but the patient
is still able to remain balanced overall. The regional sagittal
imbalance occurs without disturbing the overall spinal align-
ment, and the C7 plumb line is within 5 cm of the posterior
superior corner of the sacrum. A common example of type I
imbalance is a middle-aged woman with previous Harrington
instrumentation extending to L4-5. The patient is able to main-
tain balance by hyperextending the remaining mobile discs in
the lumbar spine. Certain congenital kyphoses, many Scheuer-
mann disease, and posttraumatic kyphosis may also result in
kyphosis, but the patients mobile segments distal to these lev-
els enable them to maintain normal sagittal balance (Fig. 90.3
and Fig. 90.4).
In type II sagittal imbalance, the regional hyperkyphosis is
such that the patient cannot balance by hyperextending the
remaining mobile segments either above or below the area of
pathology. The patients who frequently present with type II
deformity are ankylosing spondylitis patients and middle-aged
or older patients with Harrington instrumentation to the distal
segments who have experienced severe disc degeneration at
the L4-5 and L5-S1. This leads to the inability to maintain bal-
ance, and the patient then must use other mechanisms to try to
maintain upright posture. Another common problem is that of

A B C D

Figure 90.3. (A) Anteroposterior (AP) and (B) lateral scoliosis radiographs of a 43-year-old woman status
post 30 years Harrington instrumentation and fusion down to L4. Note the loss of midlumbar lordosis and
hyperextension of the L4-5 and L5-S1 disc. (C) AP and (D) lateral 2-year postoperative radiographs after the
patient had anterior discectomy, structural grafting, and multiple Smith-Petersen osteotomies.

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 942 Section VIII Adult Spinal Deformity
A B
Figure 90.4. (A) Anteroposterior (AP) and (B) lateral scoliosis radiographs on a 17-year-old female
patient with 95 Scheuermann kyphosis. (C) AP and (D) lateral 2-year postoperative radiographs after the
patient had multiple typical Smith-Petersen osteotomies and posterior instrumentation and fusion. No ante-
rior procedure was performed.
a middle-aged or older patient who, with multiple surgeries,
had the spine fixed in a hypolordotic position. This leads to
premature degeneration of the upper lumbar or distal thoracic
spine. This will again lead to the patient not being able to stand
straight and is eventually pitched forward.
More recently, a type III category has been added to the clas-
sification of sagittal imbalance. Patients with a type III deformity
have both coronal and sagittal imbalance resulting from a major
deformity in both planes. This deformity is not as common as
type I and type II sagittal imbalances. The correction of these
complex deformities can be quite difficult as both the coronal
and sagittal planes have to be taken into consideration.
Coronal imbalance has also been categorized into two dif-
ferent groups. Type I coronal imbalance includes patients in
whom one shoulder, typically the right, is high and the ipsilat-
eral pelvis is low. In this circumstance, the coronal deformity
may be corrected by simply shortening the convexity of the
deformity. In a type II coronal deformity, the shoulder relation-
ship to the pelvis is such that it cannot be corrected simply by
shortening one side of the spine (Fig. 90.5).
TREATMENT
Similar to all degenerative painful conditions, nonoperative
management should be the initial treatment of choice for
LWBK836_Ch90_p938-947.indd 942
C D
patients with symptomatic sagittal imbalance. Although symp-
tomatic improvement may be achieved in some patients with
nonoperative treatment, the likelihood of a dramatic long-term
improvement of symptomatic sagittal imbalance without sur-
gery is probably lower than for other degenerative conditions.
The underlying structural changes may be the factor leading to
this unsatisfactory response to nonoperative management.
PREOPERATIVE PLANNING
The complication rates after revision spinal surgery have been
shown to be as high as 60%, with approximately half of those
having residual sagittal imbalance.2 To minimize the likelihood
of postoperative sagittal imbalance, the preoperative planning
process must be rigorous and include a preoperative assess-
ment of sagittal alignment and a determination of the distal
limit of the fusion. Important intraoperative factors include the
use of segmental instrumentation and avoidance of distraction,
especially in the lumbar spine. Intraoperatively, the patient
should not be positioned in a manner that decreases lumbar
lordosis. Hip extension has been shown to be essential to the
preservation of anatomical lumbar lordosis.12
Appropriate preoperative clinical and radiographic evalua-
tion will provide the surgeon with the information necessary to
plan the surgical procedure or procedures for correction of the
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 Chapter 90 Sagittal Imbalance 943

A B C

Figure 90.5. (A) Anteroposterior (AP) and (B) lateral scoliosis radiographs on
a patient with type 3 sagittal plane imbalance with marked coronal and sagittal
imbalance. (C) AP and (D) lateral radiographs: patient now 1-year status post
D asymmetric pedicle subtraction osteotomy.

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 944 Section VIII Adult Spinal Deformity
Type I Deformity
Smooth Kyphosis Sharp Angular Kyphosis
Thoracic Lumbar Thoracic Lumbar Minor
Imbalance
SPOs VCR PSO
Thoracic
Figure 90.6. Treatment decision tree for type I and II sagittal imbalance. PSO, pedicle subtraction
osteotomy; SPO, Smith-Petersen osteotomy; VCR, vertebral column resection.
sagittal plane deformity. The location of the deformity, its angu-
larity and flexibility, and the magnitude of global sagittal imbal-
ance are the main factors that determine the operative strategy.
At one extreme is a stiff angular deformity in the thoracolumbar
region with significant global sagittal imbalance, which may best
be treated with a PSO or a VCR. On the other hand, a flexible,
sweeping thoracolumbar hyperkyphosis with relatively preserved
global sagittal balance may be treated with multiple SPOs. The
decision-making process regarding the type and location of the
corrective osteotomy depends on the deformity and, in reopera-
tions, the presence and location of any pseudarthrosis. An osteot-
omy through a pseudarthrosis can be used to obtain the correc-
tion of the deformity and address the nonunion while minimizing
the number of fusion surfaces. In general, corrective osteotomies
should be performed at the site of maximal deformity to achieve
maximum correction. Typically, the L2 or L3 level is the focal
point of the anatomical lumbar lordosis (Fig. 90.6).
SMITH-PETERSEN OSTEOTOMY
In 1945, Smith-Petersen et al11 described and performed the
first osteotomy for correction of flexion deformity. This proce-
dure has been modified multiple times. The basic premise is
that correction is achieved through shortening of the posterior
column with resulting anterior osteoclasis leading to lengthen-
ing of the anterior column. The ideal patient for SPO is one
with a long, rounded, smooth kyphosis without any significant
segmental angularity, such as most Scheuermann kyphosis
deformities. Multiple fixation points and mobile disc spaces are
required. As a general rule, 1 of correction can be maintained
for each millimeter of posterior bone resection, with the maxi-
mum correction per level being approximately 10. The ideal
candidate should have good bone stock, given the posterior
compression required to correct the deformity. The anterior
column lengthening creates anterior gaps, which may require
structural grafting to prevent implant loosening and maintain
the correction in the long term, particularly if the gap is greater
than 10 mm in height. Multiple SPOs can result in a harmoni-
ous reduction of hyperkyphosis or restoration of lumbar lordo-
sis. Aside from those with a smooth kyphosis, the other candidate
for this procedure is a patient with a type I sagittal imbalance
LWBK836_Ch90_p938-947.indd 944
Type II Deformity
Smooth Kyphosis Sharp Angular Kyphosis
Major Minor Major
Imbalance Imbalance Imbalance
Lumbar Thoracic Lumbar Thoracic Lumbar Thoracic Lumbar
SPOs SPOs PSO VCR PSO VCR PSO
and previous Harrington instrumentation to the L4 or L5 level.
These patients do not have significant sagittal imbalance and
therefore with multiple SPOs, reestablishment of lumbar lordo-
sis with restoration overall global balance can be achieved. If
bone-on-bone contact is established with the SPOs, anterior
reconstruction is usually not required.
PEDICLE SUBTRACTION OSTEOTOMY
The PSO is a powerful technique for the correction of type II
sagittal imbalance. This procedure is most commonly per-
formed in the lumbar spine. Although it can be performed in
the thoracic spine, the amount of correction obtained is not as
significant as it is in the lumbar spine. The decancellation pro-
cedure is a three-column posterior closing wedge osteotomy
hinging on the anterior cortex. This also has been described
previously by Heinig as the eggshell procedure.7 The operative
technique involves removal of all posterior elements at the level
of the correction including the superior and inferior facet
joints and the pedicles. The posterior-based wedge is removed
to allow correction through a shortening, posterior closure.
The osteotomy can be closed down through various maneuvers
including extension of the patients hips on the operative
frame, cantilever bending, and compression across the osteot-
omy site, as Buchowski et al5 have shown. Neural compression
leading to a temporary or permanent neurological deficit has
been reported to occur in as many as 11% and 3% of patients,
respectively.5 To ensure that the neural elements are not com-
pressed, the central canal is widened while not compromising
the stability of bone-on-bone contact.
The advantages of the PSO procedure include the ability to
achieve significant (typically, 30 to 35) correction through
one level, preservation of the anterior column, an excellent
potential for union secondary to the abundant cancellous
bone-on-bone contact and the ability, with asymmetric resec-
tion, to achieve or maintain coronal balance. The ideal candi-
dates for PSOs are patients with substantial (10 to 12 cm)
sagittal imbalance, a sharp angular kyphosis, and circumferen-
tial fusion. The PSO can be performed through areas of rota-
tional deformity or prior laminectomy. The PSO is also the
ideal procedure for patients with ankylosing spondylitis.
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 Chapter 90 Sagittal Imbalance 945

TABLE 90.2 Osteotomy Types and Characteristics

Osteotomy Type Plane of Correction Magnitude of Correction Effect on Spinal Length

Smith-Petersen Sagittal 510 Increases anteriorly,
decreases posteriorly
Pedicle subtraction Sagittal, minor coronal 3040 Decreases
Vertebral column Sagittal, coronal 30 Decreases
resection

VERTEBRAL COLUMN RESECTION SURGICAL TECHNIQUE FOR PSO

Common indications for VCR are vertebral bone congenital The patient is positioned with the hips extended. The spine is
kyphosis, a hemivertebra with a type III sagittal decompensa- exposed in the standard fashion. Fixation points are placed.
tion, a sharply angular thoracic deformity, spondyloptosis, or The ideal number of fixation points depends on where the
a resectable spinal tumor. The VCR should not be performed osteotomy is being performed. Ideally, we prefer to perform
for the treatment of isolated flatback deformity but can be the osteotomy at the L2 or L3 level. This allows for a minimum
useful in patients with fixed sagittal imbalance associated with of approximately six fixation points above and below the pro-
coronal decompensation. The procedure was first described posed osteotomy level. A laminectomy is performed by using a
by Bradford.3 This procedure consists of a vertebral body combination of Leksell rongeurs, osteotomes, and curettes to
resection including the disc cephalad and caudad with main- obtain as much bone from local decompression as possible
tenance of the cortical periosteal flap. This is accompanied by (Fig. 90.7) in the form of an SPO both cephalad and caudad to
the posterior column resection. The advantage to this proce-
dure is the dramatic correction possible of both the sagittal
and coronal planes with overall vertebral column shortening.
This, however, is an extremely demanding technical proce-
dure and can be associated with considerable perioperative
morbidity. The procedure is best performed in the thoracic
spine.

COMPARISON OF OSTEOTOMIES
The SPO will achieve approximately 1 of correction per milli-
meter of resection with a maximum of 10 per level. The opti-
mal candidates are those with good bone stock, those with
mobile discs, and those patients in whom harmonious restora-
tion of lumbar lordosis is required. The drawbacks of the pro-
cedure are that it is an anterior columnlengthening procedure
and may require anterior exposure to fill in the gaps. The
patients with ankylosed disc spaces are not candidates for this
procedure, as well as those with ankylosing spondylitis or sig- B
nificant calcification of the great vessels.
The PSO has the ability to obtain approximately 30 to 35
of correction per osteotomy level. It can achieve sagittal and
coronal correction with high union rates and it is, again, a
posterior-only procedure. The drawbacks include the technical
demands of the procedure, higher rate of blood loss, and a risk
of debilitating neurological injury. The contraindications to
this procedure are those patients with anterior instrumentation
at the same level.
With a VCR, the amount of correction is variable but does A C
hold the greatest potential for correction in both the sagittal
Figure 90.7. (A) The initial resection of the posterior elements
and the coronal planes by shortening of the spinal column.
and surrounding of the pedicles. The amount of the bone resected is
The procedure theoretically will relieve neurovascular demonstrated in the lateral view (B) in this figure. (C) Schematic dor-
tension; however, this is a very demanding procedure and sal view. (Reprinted with permission from Bridwell KH, Lewis SJ,
neurological complication rates, while not reported to date, Rinella A, Lenke LG, Baldus C, Blanke K. Pedicle subtraction osteot-
do pose a significant risk when performing the procedure omy for the treatment of fixed sagittal imbalance: surgical technique.
(Table 90.2). J Bone Joint Surg Am 2004;86A(1):4450.)

LWBK836_Ch90_p938-947.indd 945 8/26/11 2:54:09 PM

 946 Section VIII Adult Spinal Deformity
A B
Figure 90.8. (A) Decancellation of the pedicles and the vertebral
body. (B) Lateral schematic. Red area shows cancellous bone to be
removed from vertebral body. (Reprinted with permission from
Bridwell KH, Lewis SJ, Rinella A, Lenke LG, Baldus C, Blanke K. Pedi-
cle subtraction osteotomy for the treatment of fixed sagittal imbal-
ance: surgical technique. J Bone Joint Surg Am 2004;86A(1):4450.)
the pedicles. The nerve root that is exiting underneath the
pedicle should be visualized and protected. The next step is
the decancellation procedure (Fig. 90.8). The medial wall of the
pedicle is maintained to protect the traversing root while
decancellation of the pedicle and vertebral body is initiated.
Epidural vessels medial to the pedicle are controlled either
with thrombin-soaked Gelfoam or bipolar cauterization and
division. Once the maximum amount of decancellation has
A B
Figure 90.9. (A) Resection of the pedicles flush with the posterior
aspect of the vertebral body. (B) Lateral schematic view. (Reprinted
with permission from Bridwell KH, Lewis SJ, Rinella A, Lenke LG, Bal-
dus C, Blanke K. Pedicle subtraction osteotomy for the treatment of
fixed sagittal imbalance: surgical technique. J Bone Joint Surg Am
2004;86A(1):4450.)
LWBK836_Ch90_p938-947.indd 946
A B
Figure 90.10. (A) Greenstick fracture and resection of the poste-
rior vertebral cortex. (B) Lateral schematic view. (Reprinted with per-
mission from Bridwell KH, Lewis SJ, Rinella A, Lenke LG, Baldus C,
Blanke K. Pedicle subtraction osteotomy for the treatment of fixed
sagittal imbalance: surgical technique. J Bone Joint Surg Am
2004;86A(1):4450.)
been performed in the pedicle and the body, the pedicle stump
is resected to be even with the posterior wall of the vertebral
body. This is performed with a combination of Kerrison
punches and Leksell rongeurs (Fig. 90.9). The lateral walls of
the vertebral body are then exposed. Care should be taken to
remain in the subperiosteal plane to prevent iatrogenic injury
to the segmental vessels. After the lateral walls are exposed, the
completion of the posterior wall resection is performed. The
goal of this is to have the posterior wall thin enough so that it
can be easily removed with a combination of back angle curettes
and a Woodson elevator (Fig. 90.10). The final portion of the
procedure is to resect the lateral walls. The osteotomy closure
then can be performed with a combination of maneuvers. The
first is to hyperextend the patients thighs by placing blankets
or pillows underneath the proximal thighs. This will cause clo-
sure of the osteotomy. If subluxation occurs, most commonly,
the proximal elements sublux dorsally on the distal elements.
Any subluxation needs to be reduced anatomically by using the
implants. Maintaining an adequate ventral cortical bone to act
as a hinge during closure minimizes the likelihood of a signifi-
cant subluxation. Final closure of the osteotomy can be per-
formed with instrumentation (Fig. 90.11). This should have
central decompression, and care should be taken to repeatedly
check room for both the exiting roots and the central dura.
Some dural buckling can be seen and tolerated as long as there
is no compression. Neural monitoring, while essential, may not
detect an isolated nerve root injury. Therefore, it is imperative
to repeatedly check the canal and foramina for impingement.
CONCLUSION
The loss of lumbar lordosis will present with typical clinical man-
ifestations of pain and inability to stand in the upright position.
The negative impacts on the quality of life and function have
8/26/11 2:54:10 PM

A B
Figure 90.11. (A) Closure of the osteotomy and the final instru-
mentation. (B) Lateral schematic view. (Reprinted with permission
from Bridwell KH, Lewis SJ, Rinella A, Lenke LG, Baldus C, Blanke K:
Pedicle subtraction osteotomy for the treatment of fixed sagittal imbal-
ance: surgical technique. J Bone Joint Surg Am 2004;86A(1):4450.)
now been well established. The etiology of the complaints has a
wide variety of underlying pathologies. However, the goal of
treatments that can be achieved through corrective osteotomies
remains limited to three. The three most common procedures
LWBK836_Ch90_p938-947.indd 947
Chapter 90 Sagittal Imbalance 947
performed are the SPO, PSO, and VCR. The advent of third-
generation instrumentation and appropriate positioning should
lead to the decrease in the development of flatback deformity.
These newer techniques have also improved our ability to cor-
rect the problem when it occurs. Each osteotomy has inherent
risk versus benefits and should be chosen with careful preopera-
tive consideration.
REFERENCES
1. Bernhardt M, Bridwell KH. Segmental analysis of the sagittal plane alignment of
normal thoracic and lumbar spines and thoracolumbar junction. Spine 1989;14(7):
717721.
2. Booth KC, Bridwell KH, Lenke LG, Baldus CR, Blanke KM. Complications and predictive
factors for the successful treatment of flatback deformity (fixed sagittal imbalance). Spine
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