Clinical Outcomes and Complications after Pedicle Subtraction Osteotomy for Fixed Sagittal Imbalance Patients : A Long-Term Follow-Up Data

  • Hyun, Seung-Jae (Department of Neurosurgery, Seoul National University College of Medicine, Bundang Hospital) ;
  • Rhim, Seung-Chul (Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine)
  • Published : 2810.02.28


Objective : Clinical, radiographic, and outcomes assessments, focusing on complications, were performed in patients who underwent pedicle subtraction osteotomy (PSO) to assess correction effectiveness, fusion stability, procedural safety, neurological outcomes, complication rates, and overall patient outcomes. Methods : We analyzed data obtained from 13 consecutive PSO-treated patients presenting with fixed sagittal imbalances from 1999 to 2006. A single spine surgeon performed all operations. The median follow-up period was 73 months (range 41-114 months). Events during peri operative course and complications were closely monitored and carefully reviewed. Radiographs were obtained and measurements were done before surgery, immediately after surgery, and at the most recent follow-up examinations. Clinical outcomes were assessed using the Oswestry Disability Index and subjective satisfaction evaluation. Results : Following surgery, lumbar lordosis increased from $-14.1^{\circ}{\pm}20.5^{\circ}$ to $-46.3^{\circ}{\pm}12.8^{\circ}$ (p<0.0001). and the C7 plumb line improved from $115{\pm}43\;mm$ to $32{\pm}38\;mm$ (p<0.0001). There were 16 surgery-related complications in 8 patients; 3 intraoperative, 3 perioperative, and 10 late-onset postoperative. The prevalence of proximal junctional kyphosis (PJK) was 23% (3 of 13 patients). However, clinical outcomes were not adversely affected by PJK. Intraoperative blood loss averaged 2,984 mL. The C7 plumb line values and postoperative complications were closely correlated with clinical results. Conclusion : Intraoperative or postoperative complications are relatively common following PSO. Most late-onset complications in PSO patients were related to PJK and instrumentation failure. Correcting the C7 plumb line value with minimal operative complications seemed to lead to better clinical results.


  1. Ahn UM, Ahn NU, Buchowski JM, Kebaish KM, Lee JH, Song ES, et al. : Functional outcome and radiographic correction after spinal osteotomy. Spine (Phila Pa 1976) 27 : 1303-1311, 2002
  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 (Phila Pa 1976) 24 : 1712-1720, 1999
  3. Bridwell KH, Lewis SJ, Edwards C, Lenke LG, Iffrig TM, Berra A, et al. : Complications and outcomes of pedicle subtraction osteotomies for fixed sagittal imbalance. Spine (Phila Pa 1976) 28 : 2093-2101, 2003
  4. Buchowski JM, Bridwell KH, Lenke LG, Kuhns CA, Lehman RA Jr, Kim YJ, et al. : Neurologic complications of lumbar pedicle subtraction osteotomy : a 10-year assessment. Spine (Phila Pa 1976) 32 : 2245-2252, 2007
  5. Casey MP, Asher MA, Jacobs RR, Orrick JM : The effect of Harrington rod contouring on lumbar lordosis. Spine (Phila Pa 1976) 12 : 750-753, 1987
  6. Dick JC, Bourgeault CA : Notch sensitivity of titanium alloy, commercially pure titanium, and stainless steel spinal implants. Spine (Phila Pa 1976) 26 : 1668-1672, 2001
  7. Farcy JP, Schwab FJ : Management of flatback and related kyphotic decompensation syndromes. Spine (Phila Pa 1976) 22 : 2452-2457, 1997
  8. Ikenaga M, Shikata J, Takemoto M, Tanaka C : Clinical outcomes and complications after pedicle subtraction osteotomy for correction of thoracolumbar kyphosis. J Neurosurg Spine 6 : 330-336, 2007
  9. Jaffray D, Becker V, Eisenstein S : Closing wedge osteotomy with transpedicular fixation in ankylosing spondylitis. Clin Orthop Relat Res : 122-126, 1992
  10. Jang JS, Jung BJ, Lee SH : Pedicle subtraction and extension wedge osteotomy for the correction of fixed kyphotic deformity of the lumbar spine : technical note. J Korean Neurosurg Soc 33 : 230-233, 2003
  11. Kim KT, Suk KS, Cho YJ, Hong GP, Park BJ : Clinical outcome results of pedicle subtraction osteotomy in ankylosing spondylitis with kyphotic deformity. Spine (Phila Pa 1976) 27 : 612-618, 2002
  12. Kim YJ, Bridwell KH, Lenke LG, Glattes CR, Rhim S, Cheh G : Proximal junctional kyphosis in adult spinal deformity after segmental posterior spinal instrumentation and fusion : minimum fiveyear follow-up. Spine (Phila Pa 1976) 33 : 2179-2184, 2008
  13. Murrey DB, Brigham CD, Kiebzak GM, Finger F, Chewning SJ : Transpedicular decompression and pedicle subtraction osteotomy (eggshell procedure) : a retrospective review of 59 patients. Spine (Phila Pa 1976) 27 : 2338-2345, 2002
  14. Peretz AM, Hipp JA, Heggeness MH : The internal bony architecture of the sacrum. Spine (Phila Pa 1976) 23 : 971-974, 1998
  15. Smith-Petersen MN, Larson CB, Aufranc OE : Osteotomy of the spine for correction of flexion deformity in rheumatoid arthritis. Clin Orthop Relat Res 66 : 6-9, 1969
  16. Yang BP, Ondra SL, Chen LA, Jung HS, Koski TR, Salehi SA : Clinical and radiographic outcomes of thoracic and lumbar pedicle subtraction osteotomy for fixed sagittal imbalance. J Neurosurg Spine 5 : 9-17, 2006