CHAPTER
94
Smith-Petersen Osteotomy
of the Spine
INTRODUCTION
Fixed sagittal imbalance is an increasingly seen problem among
spine patients. The reasons for this are multifactorial. More
spine fusions are done each year than in the past, leading to
junctional problems as well as problems within the treated
region. Better surgical and anesthetic techniques are allowing
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-
ance by spine surgeons may be leading to increased recognition
of the problem.
The options for treating fixed sagittal imbalance have
increased in the last two decades. Pedicle subtraction, or egg-
shell, osteotomies are routinely performed by those experi-
enced in its technique and vertebral column resections are
beginning to be done with increasing frequency as well. The
oldest osteotomy is the Smith-Petersen osteotomy. It was first
performed more than 60 years ago and remains a valuable tool
for the spinal deformity surgeon. The purpose of this chapter is
to review the history, indications, technique, and results of the
Smith-Petersen osteotomy.
HISTORY
Osteotomy of the spine was first reported by Smith-Petersen et
al in 194520 as a treatment for sagittal imbalance due to
ankylosing spondylitis (AS). He reported on six patients treated
with the posterior opening wedge osteotomy that now bears his
name. All patients were immobilized in a plaster cast for a
year.
La Chapelle12 reported a year later on a similar osteotomy,
although done in two stages with a second anterior operation
performed to divide the ossified anterior longitudinal ligament
under direct vision. Several other early authors6,8,11,14,17,21 pub-
lished on the Smith-Petersen osteotomy in the treatment of AS.
Adams1 reported on a modification of the technique, perform-
ing the surgery in a lateral, rather than a prone, position.
Meiss18 in 1955 was the first to apply this technique to a
diagnosis other than AS, when he performed a two-stage
biplanar correction of a patient previously fused with a severe
kyphoscoliosis.18 This early article highlights the two different
982
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Douglas C. Burton
ways this technique can be applied, depending on the diag-
nosis. AS, due to the brittle nature of the anterior column,
allows for an anterior osteoclasis from a posterior-only
approach. Other diagnoses do not allow this, thus to obtain
larger corrections (greater than 10 to 15 per level); one
must perform multiple-level osteotomies with or without
anterior release.
INDICATIONS
The indication for an osteotomy of the spine is spinal imbal-
ance in the sagittal and/or coronal plane that does not correct
on bending radiographs. The options for osteotomy are many.
In addition to the Smith-Petersen osteotomy, posterior osteot-
omy techniques include the pedicle subtraction osteotomy,22
also referred to as an eggshell osteotomy.10 This can then be
combined with anterior discectomy or osteotomy. The choice
of technique depends on the amount of deformity correction
desired and the etiology of the deformity.
The Smith-Petersen osteotomy was devised to treat sagittal
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.
It was this aspect of the technique that allowed for the large
corrections obtained. Smith-Petersens original description of
the technique used elevation of the head and feet to affect the
anterior column osteoclasis.20 La Chapelle12 used a second-
stage anterior approach to osteotomize the bamboo spine. In
either approach, the correction is obtained through an ante-
rior opening wedge osteotomy. The fulcrum of the osteotomy is
the posterior longitudinal ligament, and the amount of angular
correction is limited by the amount of anterior opening. A cal-
cified aorta is a contraindication to this procedure due to the
potential for aortic rupture.15
If the patient does not have AS, then osteoclasis cannot be
performed. This limits considerably the amount of correction
that can be obtained. Without anterior osteoclasis, each milli-
meter of posterior bone resection yield 1 of angular correc-
tion up to 10 to 15.3 This is also reliant upon relatively fat
anterior discs, at least 5 mm in height without bridging osteo-
phytes.3 If the discs are narrowed, an anterior release may be
necessary to obtain the desired correction.
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TECHNIQUE
We utilize spinal monitoring, including transcranial motor
evoked potentials, somatosensory evoked potentials and con-
tinuous electromyograms for all our osteotomies. Central
venous line, arterial line, Foley catheter, and nasogastric tube
are placed. The patient is carefully positioned prone on a
ReltonHall frame. If there is any question as to neck stability,
such as in AS, the head is placed in Mayfield tongs. We have not
routinely used a flexed bed for positioning, although, at times,
it is helpful.
The choice of osteotomy level depends on the apex of the
deformity. The normal apex of the lumbar lordosis is L3-4, and
this is the level usually chosen when treating AS. If the defor-
mity is something other than AS, the osteotomy is done at mul-
tiple levels across the region of the deformity.
Once the patient is positioned, the spine is exposed. We
place our spinal fixation at this time. This allows for the use of
a temporary stabilizing rod if the spine becomes unstable
before the osteotomy is completed, and it allows for rapid clo-
sure of the osteotomy when it is ready. This maneuver usually
diminishes the epidural bleeding that occurs.
It is important to identify the pedicles above and below the
osteotomy site. This is usually done by dissecting out the trans-
verse processes. The resection is wedge or chevron shaped, with
the point distal (Fig. 94.1). In the setting of intact posterior ele-
ments, such as in AS, the initial resection is of the spinous pro-
cess at the level to be resected. Portions of the spinous pro-
cesses above and below are also removed. It is important to
keep both limbs of the wedge symmetrical, unless some coronal
plane correction is desired, in which case, one side is widened
with respect to the other. We prefer to outline the area to be
resected with an oscillating saw or osteotome from the apex of
the wedge out laterally to the notch. The bone between the cut
lines is then thinned with an osteotome. This preserves as much
local bone as possible for the arthrodesis.
Figure 94.1. Drawing of the osteotomy after resection of the
spinous processes and facet joints and before the closure is
performed.
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Chapter 94 Smith-Petersen Osteotomy of the Spine 983
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-
ting of AS, the dura may be very adherent to the ossified ligamen-
tum flavum. Incidental durotomies are repaired prior to closure
of the osteotomy. The osteotomy is carried laterally with small
Kerrison rongeurs out to the intervertebral notch. Epidural bleed-
ing is controlled with thrombin-soaked Gelfoam and Cottonoid.
Special care is taken to undercut the osteotomy centrally so as to
avoid any neural compression associated with closing the osteot-
omy. If there is any indication of dural compression during
osteotomy closure, the osteotomy should be enlarged centrally.
If the osteotomy is performed at a level with significant rota-
tional deformity, the osteotomy should be opened greater on the
side of the convexity as suggested by Bridwell et al.4 This is to avoid
coronal plane decompensation when the osteotomy is closed.
Once the osteotomy is completed, closure of the osteotomy
is performed. This may occur passively due to the lordosis
induced by the operative frame. The prebent rods are added to
the bone anchors already present and combination maneuvers
of cantilever correction and compression should affect the nec-
essary reduction. If osteoclasis is to be performed, manual pres-
sure on the fusion mass or elevation of the feet may aid in the
anterior column fracture (Fig. 94.2). This should be done in a
slow and controlled manner. Once the correction is completed
and the rods are set, it is imperative to obtain intraoperative
radiographs to verify appropriate sagittal and coronal balance.
We use 36-in. posteroanterior radiographs double exposed
proximally and distally with a sterile wrapped lead apron pro-
tecting the nonexposed portion of the cassette to assess coronal
balance. A lateral 17-in. 14-in. radiograph is used to docu-
ment the sagittal correction. It is at this point that the surgeon
must be certain that adequate correction has been obtained.
Failure to achieve appropriate sagittal alignment will result in
an unsatisfied patient.
If the deformity is due to a condition other than AS, then the
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
no complications. These early reports did not document the
amount of correction obtained but noted that almost all
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
with extension osteotomy. His average correction was 25 to
45. His complications included eight perioperative deaths, two
from gastrointestinal causes and six neurological injuries.
Recurrence of deformity occurred in three patients. This is the
largest series in the early literature and the one most often
cited for rates of death and neurological injury.
Goel8 studied 15 patients treated with a Smith-Petersen
osteotomy in 1968. His average correction was 37, and he
Smith-Petersen Osteotomy
TABLE 94.1
Surgical Sequence
1. Initiation of anesthetic, placement of monitoring lines,
nasogastric tube, and placement of leads for motor evoked and
somatosensory evoked potentials
2. Careful positioning on operative frame to maximize lordosis
(if possible)
3. Exposure and placement of all anchors (screws, hooks, wires)
4. Decompression and posterior interbody fusions (if done at level
different from the planned osteotomies)
5. Preparation of rods (cut and contoured)
6. Performance of the osteotomies
7. Placement of rods and closure of osteotomies
8. Sagittal and 36-in. coronal radiographs
9. Confirmation of neuromonitoring status
reported seven complications, including two pressure sores,
two cases of ileus, two root irritations, and one deformity recur-
rence. Emnus6 reported on an additional five patients in 1968
with an average correction of 24 and complications of one
dural laceration and one pseudarthrosis.
Camargo et al5 reported on 66 patients the following year
with corrections ranging from 22 to 55. Their complications
included one ileus, one aortic rupture, and two neurological
deficits that recovered spontaneously.
In 1977, Simmons19 published on a variation of the original
technique. He maintained the technical details of the osteot-
omy as they were originally described but performed the opera-
tion in the lateral position under local anesthetic. He was able
to achieve an average correction of 47 with no reported com-
plications. He routinely left the nasogastric tube in place for 2
to 3 days postoperatively, as other authors have suggested,
avoiding gastrointestinal complications. He utilized spinous
process wiring and external casting for immobilization.
By 1970s, surgeons had begun adding Harrington instru-
mentation to the procedure for additional internal fixation. In
1985, McMaster16 published on the use of modified Harrington
compression instrumentation to aid in both the correction
maneuver and the postsurgical immobilization. He treated 14
patients and obtained an average 38 correction maintained at
33 at final follow-up. He reported complications including
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
osteotomy and reported on eight patients treated with poste-
rior osteotomy alone and compression instrumentation. They
experienced four complications in these eight patients, includ-
ing two partial neurological injuries that resolved, two hook
cutouts, and one ileus.
The development of pedicle screw systems in the 1980s led
to its use in internal fixation after the osteotomy. Hehne et al9
reported on 177 patients treated with polysegmental osteoto-
mies and pedicle screw fixation in 1990. They reported an aver-
age correction of 10 per osteotomy. They reported 4 deaths,
4 permanent root injuries, 19 resolved neurological deficits,
4 cases of implant failure, and 6 deep wound infections.
van Royen et al23 subsequently reported on the same opera-
tion in 21 patients with an average correction of 25. They had
nine instances of implant failure and seven deep wound infec-
tions. They no longer recommend polysegmental osteotomies
for deformity correction in AS.
All of these reports highlight the numerous difficulties one
faces when performing this operation. Even in the hands of
master surgeons, complications are relatively common.
RESULTSDEFORMITY SALVAGE
The increased utilization of surgical treatment for scoliosis that
followed the advent of Harrington instrumentation also led to
complex revision operations (Fig. 94.3). The term flatback
syndrome, arising from iatrogenic lumbar lordosis loss, was
popularized by LaGrone et al13 in 1988. They identified the use
of distraction instrumentation in the lumbar spine as the most
common etiology of this disorder. To treat this problem, they
performed 66 osteotomies on 55 patients, with 19 concomitant
anterior procedures. There were 33 complications but no
deaths or permanent neurological deficits. The anterior sagit-
tal displacement improved from 8.2 cm preoperatively to an
average 0.1 cm after surgery and 4.2 cm at final follow-up.
Twenty-six patients felt they were still leaning forward after sur-
gery with an average displacement of 5.4 cm. This is contrasted
with 24 patients, who did not feel they were leaning forward
with an average displacement of 1.3 cm. This highlights the
points that in revision surgery for sagittal imbalance, patients
will not be satisfied unless adequate lordosis is restored.
Floman et al7 reported on 154 osteotomies in 55 patients
who required revision surgery due to imbalance following pre-
vious spine fusion. Nine patients had additional anterior sur-
gery. There were 32 complications, including 1 death and
9 neurological deficits, 8 of which resolved. Spinal imbalance
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
with rigid deformity treated with multiple osteotomies. The
average sagittal balance was corrected by 6.5 cm. They had nine
complications in eight patients, including three pseudarthroses,
five implant failures, and one transient neurological deficit.
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.

SUMMARY
Smith-Petersens admonition, The operative procedure must
not be belittled, there are many points in the technique that we
have found difficult, remains as true today as it was in 1945.20
The complication rate associated with this procedure is high,
whether performed in the setting of AS or for iatrogenic spinal
imbalance in the multiply operated patient. The keys to success
lie in careful assessment of the deformity and the amount of cor-
rection desired, understanding of the deformity etiology and
comorbidities, meticulous surgical technique, and prompt atten-
tion to postoperative complications when they are encountered.
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