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CHAPTER

94 Douglas C. Burton

Smith-Petersen Osteotomy
of the Spine

INTRODUCTION ways this technique can be applied, depending on the diag-


nosis. AS, due to the brittle nature of the anterior column,
Fixed sagittal imbalance is an increasingly seen problem among allows for an anterior osteoclasis from a posterior-only
spine patients. The reasons for this are multifactorial. More approach. Other diagnoses do not allow this, thus to obtain
spine fusions are done each year than in the past, leading to larger corrections (greater than 10 to 15 per level); one
junctional problems as well as problems within the treated must perform multiple-level osteotomies with or without
region. Better surgical and anesthetic techniques are allowing anterior release.
patients not previously thought to be acceptable candidates for
surgery to be safely and successfully treated operatively. In addi-
tion, increased recognition of the problem of sagittal imbal- INDICATIONS
ance by spine surgeons may be leading to increased recognition
of the problem. The indication for an osteotomy of the spine is spinal imbal-
The options for treating fixed sagittal imbalance have ance in the sagittal and/or coronal plane that does not correct
increased in the last two decades. Pedicle subtraction, or egg- on bending radiographs. The options for osteotomy are many.
shell, osteotomies are routinely performed by those experi- In addition to the Smith-Petersen osteotomy, posterior osteot-
enced in its technique and vertebral column resections are omy techniques include the pedicle subtraction osteotomy,22
beginning to be done with increasing frequency as well. The also referred to as an eggshell osteotomy.10 This can then be
oldest osteotomy is the Smith-Petersen osteotomy. It was first combined with anterior discectomy or osteotomy. The choice
performed more than 60 years ago and remains a valuable tool of technique depends on the amount of deformity correction
for the spinal deformity surgeon. The purpose of this chapter is desired and the etiology of the deformity.
to review the history, indications, technique, and results of the The Smith-Petersen osteotomy was devised to treat sagittal
Smith-Petersen osteotomy. deformity due to AS. Because of the brittle nature of the ossi-
fied anterior longitudinal ligament and disc, an anterior osteo-
clasis or fracture was performed through the anterior column.
HISTORY It was this aspect of the technique that allowed for the large
corrections obtained. Smith-Petersens original description of
Osteotomy of the spine was first reported by Smith-Petersen et the technique used elevation of the head and feet to affect the
al in 194520 as a treatment for sagittal imbalance due to anterior column osteoclasis.20 La Chapelle12 used a second-
ankylosing spondylitis (AS). He reported on six patients treated stage anterior approach to osteotomize the bamboo spine. In
with the posterior opening wedge osteotomy that now bears his either approach, the correction is obtained through an ante-
name. All patients were immobilized in a plaster cast for a rior opening wedge osteotomy. The fulcrum of the osteotomy is
year. the posterior longitudinal ligament, and the amount of angular
La Chapelle12 reported a year later on a similar osteotomy, correction is limited by the amount of anterior opening. A cal-
although done in two stages with a second anterior operation cified aorta is a contraindication to this procedure due to the
performed to divide the ossified anterior longitudinal ligament potential for aortic rupture.15
under direct vision. Several other early authors6,8,11,14,17,21 pub- If the patient does not have AS, then osteoclasis cannot be
lished on the Smith-Petersen osteotomy in the treatment of AS. performed. This limits considerably the amount of correction
Adams1 reported on a modification of the technique, perform- that can be obtained. Without anterior osteoclasis, each milli-
ing the surgery in a lateral, rather than a prone, position. meter of posterior bone resection yield 1 of angular correc-
Meiss18 in 1955 was the first to apply this technique to a tion up to 10 to 15.3 This is also reliant upon relatively fat
diagnosis other than AS, when he performed a two-stage anterior discs, at least 5 mm in height without bridging osteo-
biplanar correction of a patient previously fused with a severe phytes.3 If the discs are narrowed, an anterior release may be
kyphoscoliosis.18 This early article highlights the two different necessary to obtain the desired correction.

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Chapter 94 Smith-Petersen Osteotomy of the Spine 983

TECHNIQUE The canal is entered in the midline and a dural elevator is


used to free any dural adhesions that may be present. In the set-
We utilize spinal monitoring, including transcranial motor ting of AS, the dura may be very adherent to the ossified ligamen-
evoked potentials, somatosensory evoked potentials and con- tum flavum. Incidental durotomies are repaired prior to closure
tinuous electromyograms for all our osteotomies. Central of the osteotomy. The osteotomy is carried laterally with small
venous line, arterial line, Foley catheter, and nasogastric tube Kerrison rongeurs out to the intervertebral notch. Epidural bleed-
are placed. The patient is carefully positioned prone on a ing is controlled with thrombin-soaked Gelfoam and Cottonoid.
ReltonHall frame. If there is any question as to neck stability, Special care is taken to undercut the osteotomy centrally so as to
such as in AS, the head is placed in Mayfield tongs. We have not avoid any neural compression associated with closing the osteot-
routinely used a flexed bed for positioning, although, at times, omy. If there is any indication of dural compression during
it is helpful. osteotomy closure, the osteotomy should be enlarged centrally.
The choice of osteotomy level depends on the apex of the If the osteotomy is performed at a level with significant rota-
deformity. The normal apex of the lumbar lordosis is L3-4, and tional deformity, the osteotomy should be opened greater on the
this is the level usually chosen when treating AS. If the defor- side of the convexity as suggested by Bridwell et al.4 This is to avoid
mity is something other than AS, the osteotomy is done at mul- coronal plane decompensation when the osteotomy is closed.
tiple levels across the region of the deformity. Once the osteotomy is completed, closure of the osteotomy
Once the patient is positioned, the spine is exposed. We is performed. This may occur passively due to the lordosis
place our spinal fixation at this time. This allows for the use of induced by the operative frame. The prebent rods are added to
a temporary stabilizing rod if the spine becomes unstable the bone anchors already present and combination maneuvers
before the osteotomy is completed, and it allows for rapid clo- of cantilever correction and compression should affect the nec-
sure of the osteotomy when it is ready. This maneuver usually essary reduction. If osteoclasis is to be performed, manual pres-
diminishes the epidural bleeding that occurs. sure on the fusion mass or elevation of the feet may aid in the
It is important to identify the pedicles above and below the anterior column fracture (Fig. 94.2). This should be done in a
osteotomy site. This is usually done by dissecting out the trans- slow and controlled manner. Once the correction is completed
verse processes. The resection is wedge or chevron shaped, with and the rods are set, it is imperative to obtain intraoperative
the point distal (Fig. 94.1). In the setting of intact posterior ele- radiographs to verify appropriate sagittal and coronal balance.
ments, such as in AS, the initial resection is of the spinous pro- We use 36-in. posteroanterior radiographs double exposed
cess at the level to be resected. Portions of the spinous pro- proximally and distally with a sterile wrapped lead apron pro-
cesses above and below are also removed. It is important to tecting the nonexposed portion of the cassette to assess coronal
keep both limbs of the wedge symmetrical, unless some coronal balance. A lateral 17-in. 14-in. radiograph is used to docu-
plane correction is desired, in which case, one side is widened ment the sagittal correction. It is at this point that the surgeon
with respect to the other. We prefer to outline the area to be must be certain that adequate correction has been obtained.
resected with an oscillating saw or osteotome from the apex of Failure to achieve appropriate sagittal alignment will result in
the wedge out laterally to the notch. The bone between the cut an unsatisfied patient.
lines is then thinned with an osteotome. This preserves as much If the deformity is due to a condition other than AS, then the
local bone as possible for the arthrodesis. amount of correction will be limited to 5 to 10 of correction at
any one level. This can be increased with anterior releases. This
has led to the use of the posterior/anterior/posterior sequence
for deformity correction. The initial stage is typically posterior
instrumentation placement with posterior osteotomies. The sec-
ond stage is anterior or anteriorlateral approach to the spine
with wide anterior release/osteotomies. The third and final
stage is posterior closure of the osteotomy and rod placement
and arthrodesis (Figs. 94.3 and 94.4). This can be done sequen-
tially in 1 day or staged in 2 days. We will stage the operation and
perform it on 2 days separated by 48 hours if we believe the
operative time will exceed 12 hours (Table 94.1).

RESULTSANKYLOSING SPONDYLITIS
Smith-Petersen et al20 published on six patients in 1945. They
reported good outcomes in all with the only complication a
retained iliac sponge. In 1948, Herbert11 reported on four
patients treated with osteotomy. Sotelo-Ortiz21 reported on an
additional two patients in 1958, both with good outcomes but
with temporary anterior thigh paresthesias. McMaster17 added
five patients to the literature in 1958, all with good results and
Figure 94.1. Drawing of the osteotomy after resection of the no complications. These early reports did not document the
spinous processes and facet joints and before the closure is amount of correction obtained but noted that almost all
performed. patients were satisfied with their outcomes.

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984 Section VIII Adult Spinal Deformity

A B C

Figure 94.2. (A) Preoperative lateral radiograph of a 36-year-old man with ankylosing spondylitis and sag-
ittal imbalance. (B) Immediate postoperative radiograph after Smith-Petersen osteotomy and spinous process
wiring showing 41 correction. Patient was immobilized in a cast for 6 months. (C) Eighteen months after
surgery, the patient has lost 16 of correction but is satisfied with the result.

In 1959, Law14 published his results on 80 patients treated reported seven complications, including two pressure sores,
with extension osteotomy. His average correction was 25 to two cases of ileus, two root irritations, and one deformity recur-
45. His complications included eight perioperative deaths, two rence. Emnus6 reported on an additional five patients in 1968
from gastrointestinal causes and six neurological injuries. with an average correction of 24 and complications of one
Recurrence of deformity occurred in three patients. This is the dural laceration and one pseudarthrosis.
largest series in the early literature and the one most often Camargo et al5 reported on 66 patients the following year
cited for rates of death and neurological injury. with corrections ranging from 22 to 55. Their complications
Goel8 studied 15 patients treated with a Smith-Petersen included one ileus, one aortic rupture, and two neurological
osteotomy in 1968. His average correction was 37, and he deficits that recovered spontaneously.
In 1977, Simmons19 published on a variation of the original
technique. He maintained the technical details of the osteot-
Smith-Petersen Osteotomy omy as they were originally described but performed the opera-
TABLE 94.1
Surgical Sequence tion in the lateral position under local anesthetic. He was able
to achieve an average correction of 47 with no reported com-
1. Initiation of anesthetic, placement of monitoring lines,
plications. He routinely left the nasogastric tube in place for 2
nasogastric tube, and placement of leads for motor evoked and
to 3 days postoperatively, as other authors have suggested,
somatosensory evoked potentials
2. Careful positioning on operative frame to maximize lordosis avoiding gastrointestinal complications. He utilized spinous
(if possible) process wiring and external casting for immobilization.
3. Exposure and placement of all anchors (screws, hooks, wires) By 1970s, surgeons had begun adding Harrington instru-
4. Decompression and posterior interbody fusions (if done at level mentation to the procedure for additional internal fixation. In
different from the planned osteotomies) 1985, McMaster16 published on the use of modified Harrington
5. Preparation of rods (cut and contoured) compression instrumentation to aid in both the correction
6. Performance of the osteotomies maneuver and the postsurgical immobilization. He treated 14
7. Placement of rods and closure of osteotomies patients and obtained an average 38 correction maintained at
8. Sagittal and 36-in. coronal radiographs
33 at final follow-up. He reported complications including
9. Confirmation of neuromonitoring status
three dural tears and two cases of ileus. Bradford et al2 also

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Chapter 94 Smith-Petersen Osteotomy of the Spine 985

utilized Harrington instrumentation with the Smith-Petersen syndrome, arising from iatrogenic lumbar lordosis loss, was
osteotomy and reported on eight patients treated with poste- popularized by LaGrone et al13 in 1988. They identified the use
rior osteotomy alone and compression instrumentation. They of distraction instrumentation in the lumbar spine as the most
experienced four complications in these eight patients, includ- common etiology of this disorder. To treat this problem, they
ing two partial neurological injuries that resolved, two hook performed 66 osteotomies on 55 patients, with 19 concomitant
cutouts, and one ileus. anterior procedures. There were 33 complications but no
The development of pedicle screw systems in the 1980s led deaths or permanent neurological deficits. The anterior sagit-
to its use in internal fixation after the osteotomy. Hehne et al9 tal displacement improved from 8.2 cm preoperatively to an
reported on 177 patients treated with polysegmental osteoto- average 0.1 cm after surgery and 4.2 cm at final follow-up.
mies and pedicle screw fixation in 1990. They reported an aver- Twenty-six patients felt they were still leaning forward after sur-
age correction of 10 per osteotomy. They reported 4 deaths, gery with an average displacement of 5.4 cm. This is contrasted
4 permanent root injuries, 19 resolved neurological deficits, with 24 patients, who did not feel they were leaning forward
4 cases of implant failure, and 6 deep wound infections. with an average displacement of 1.3 cm. This highlights the
van Royen et al23 subsequently reported on the same opera- points that in revision surgery for sagittal imbalance, patients
tion in 21 patients with an average correction of 25. They had will not be satisfied unless adequate lordosis is restored.
nine instances of implant failure and seven deep wound infec- Floman et al7 reported on 154 osteotomies in 55 patients
tions. They no longer recommend polysegmental osteotomies who required revision surgery due to imbalance following pre-
for deformity correction in AS. vious spine fusion. Nine patients had additional anterior sur-
All of these reports highlight the numerous difficulties one gery. There were 32 complications, including 1 death and
faces when performing this operation. Even in the hands of 9 neurological deficits, 8 of which resolved. Spinal imbalance
master surgeons, complications are relatively common. was improved to within 2 cm on average and only five patients
continued to complain of back pain.
More recently Voos et al24 have reported on 27 patients
RESULTSDEFORMITY SALVAGE with rigid deformity treated with multiple osteotomies. The
average sagittal balance was corrected by 6.5 cm. They had nine
The increased utilization of surgical treatment for scoliosis that complications in eight patients, including three pseudarthroses,
followed the advent of Harrington instrumentation also led to five implant failures, and one transient neurological deficit.
complex revision operations (Fig. 94.3). The term flatback There were no deaths or permanent neurological deficits.

A B C D

Figure 94.3. (A) Posteroanterior (PA) and (B) lateral 36-in. radiographs of a 16-year-old boy with
congenital scoliosis. He has had two previous anterior surgeries and one anterior and posterior surgery. He
has a presumed pseudarthrosis and broken anterior implants with thoracolumbar junctional kyphosis of 61.
(C) Postoperative PA and (D) lateral radiographs after staged reconstruction. The initial stage consisted of
anchor placement and three Smith-Petersen osteotomies through his fusion mass. Stage two consisted of
anterior implant removal, osteotomy and pseudarthrosis takedown, and sequential posterior implant
placement and deformity correction. Note the correction of both the kyphosis and the coronal imbalance.

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986 Section VIII Adult Spinal Deformity

A B C D

Figure 94.4. (A) Posteroanterior (PA) and (B) lateral radiographs of a 35-year-old woman with fixed sagit-
tal imbalance after a previous L3-S1 noninstrumented arthrodesis. (C) PA and (D) lateral radiographs 18
months after staged posterior/anterior/posterior operation. The initial stage consisted of placement of the
lumbar pedicle screws and Smith-Petersen osteotomies at each level. The second stage was done 2 days later
with wide anterior discectomies and placement of structural, fresh, frozen, femoral ring allografts followed
sequentially by posterior placement of the rods, closing of the osteotomies, and bone grafting. Patient has
minimal pain, takes no opioids, and has returned to a sedentary occupation.

7. Floman Y, Penny N, Micheli LJ, Riseborough EJ, Hall JE. Osteotomy of the fusion mass in
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ankylosing spondylarthritis. J Bone Joint Surg Am 1946;28:851858.
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