CHAPTER
93
Revision Surgeries for Adult
Spinal Deformity
INTRODUCTION
Patients in need of spine revision deformity surgery present
complex clinical challenges. Failure of the index surgical cor-
rection, or a new spinal problem, requires characterization
through a complete history and physical examination supple-
mented with confirmatory diagnostic evaluations. Confirmatory
studies include radiographs and three-dimensional imaging,
blood work, and electrophysiologic testing that solidify the diag-
nosis and shape the plan for salvage surgery. With a definitive
diagnosis established, appropriate preoperative medical consul-
tations can be obtained, and the surgical intervention can be
undertaken for best outcome. Revision spine deformity surgery
patients should receive their care in the setting of a multidisci-
plinary team to ensure optimal preoperative assessment, intra-
operative reconstruction, and postoperative convalescence.
Nonoperative management should always be considered in
the initial treatment of the revision deformity surgery patient.
Care delivered by primary medical physicians, pain manage-
ment or physiatry specialists, and spinal surgeons will include
nonsteroidal anti-inflammatory medications, opiate medica-
tions delivered orally or by implanted pain pumps, physical
therapy, spinal injections, and possibly braces or abdominal cor-
sets. Rigorous physical therapy, combined with appropriate pain
management, improves function and the quality of life in most
patients but will be less successful in some cases. Patients failing
conservative management and in need of revision surgery fre-
quently have significant narcotic requirements to control pain
symptoms and are very limited in their activities of daily living.
The relative condition of patients preoperatively will influence
their postoperative course, as regards difficulty with pain man-
agement and mobilization, and attempts must be made prior to
revision surgery to decrease opiate tolerance and maximize
physical functioning. Similarly, patients requiring deformity
surgery present with multiple medical comorbidities in need of
optimization and patients requiring revision deformity surgery
have been shown to be further debilitated.16 Careful patient
assessment and optimization preoperatively will result in better
tolerance of surgery and may reduce medical complications.
Primary and revision spinal surgery statistics for the United
States have recently been described by Ong et al.22 They esti-
mate that 228,000 primary lumbar fusions and 27,000 primary
thoracic fusion procedures were performed in 2005, and an
970
LWBK836_Ch93_p970-981.indd 970
Matthew E. Cunningham
Oheneba Boachie-Adjei
overall revision surgery rate of approximately 5.2% of the index
rates. This estimate for revision surgery is smaller than the
13.8% rate reported for lumbar fusions in Washington State for
the period 1997 to 2000.20 It is expected that requirement for
revision surgery in the adult spinal deformity population is at
least as frequent as the degenerative population, due to the
longer average length of fusions used in deformity reconstruc-
tion and the consequent higher risks for pseudarthrosis,
implant problems, and adjacent-level pathology.11,13,16 Specific
to pseudarthrosis, Kim et al11 have reported a 17% incidence in
adult patients after primary deformity surgery, with risk factors
identified as thoracolumbar kyphosis 20 or more, age more
than 55 years, and fusions involving more than 12 vertebrae.
Other reasons for revision deformity surgery include progres-
sive coronal or sagittal imbalance6,12,15,28 and subjacent facet or
disc degeneration causing symptoms of stenosis, radicular leg
pain, and back pain.7,8 Adjacent segment degeneration has
been shown to be more frequent in fusions terminating in the
distal lumbar spine, with those terminating at the lumbosacral
junction being the most affected.8 Proximal junctional kyphosis
has been reported in 26% of adult deformity patients at
minimum 2-year follow-up, but no risk factors have been
identified.10
Revision spine deformity surgery can be much more chal-
lenging than primary deformity reconstruction due to the
health and functional status of the patients, altered surgical
anatomy, and requirement for complex osteotomies and instru-
mentation to obtain and maintain reduction of the deformed
spine. Despite these concerns, excellent clinical results can be
obtained in revision spine deformity reconstruction for the
properly selected and surgically indicated patient.
CLINICAL PRESENTATION
Pain, a common symptom, may be reported in the axial spine,
lower extremities, or as a combination of both. Obtaining a
comprehensive history from the patient concerning the pain
symptoms prior to the index procedure, in the perioperative
period, and in the interval since surgery may help to establish
the etiology of the current symptoms. Other common symp-
toms that patients report include progression of deformity
including loss of height and differences in the fit of clothing,
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 Chapter 93 Revision Surgeries for Adult Spinal Deformity 971

A B C D

Figure 93.1. A 72-year-old woman with previous posterior-only long

fusion to the pelvis that underwent multiple-level instrumentation failure
(panel A, lateral radiograph). She had partial removal of implants and
later showed progression of deformity consistent with pseudarthrosis
(panel B, lateral radiograph). The patient underwent staged anterior spi-
nal fusion and posterior osteotomies with instrumented fusion (panel C
and D, anteroposterior and lateral radiographs) that resulted in restora-
tion of spinal balance (preoperative clinical photograph, panel E; postop-
E F
erative, panel F).

LWBK836_Ch93_p970-981.indd 971 8/26/11 10:02:35 PM

 972 Section VIII Adult Spinal Deformity
coronal, or sagittal decompensation including the report of
falling to the side or falling forward, and less frequently
lower extremity neurological symptoms including weakness of
foot and ankle extensor muscle strength. It is the responsibility
of the treating surgeon to understand completely the indica-
tions for the prior surgeries, to understand what procedures
were performed, and to have an idea for why these interven-
tions failed before indicating the patient for another poten-
tially ineffective surgery. Important questions to ask include:
was there relief from symptoms after the first procedure? When
did the symptoms return? What is the most troubling symptom
that you experience? Symptoms may return immediately after
surgery, or there may be symptom-free periods of decades after
the index procedure. Similarly, gradual return of symptoms
implies a degenerative etiology for the spine pathology, where
sudden return of symptoms would be consistent either with
instability from instrumentation failure or with infection.
Obtaining a complete description of the timing, character,
intensity, and behavior of the presenting symptoms will typi-
cally allow the surgeon to generate a differential diagnosis that
can be narrowed by utilizing imaging, laboratory, and neuro-
physiological testing.
Several spine pathologies can reproduce pain symptoms in
the region of the prior fusion. Standard concerns are for infec-
tion, pseudarthrosis, failure of instrumentation, and painful
instrumentation. The history and physical examination will
help to indicate which of these possibilities is most likely. For a
patient with a history of intermittent fevers, who also has a
warm, tender, or swollen wound on examination, suspicion for
infection should be very high; blood cultures, complete blood
count (CBC), and baseline inflammatory markers should be
checked to help confirm the diagnosis. A patient with new
onset point tenderness to gentle palpation over a prominent
implant could indicate symptomatic instrumentation, early
infection, or loss of instrumentation fixation if this is in the set-
ting of a change in posture; correlation of the physical exami-
nation should be made with findings from serial radiographs
taken after the index fusion. Pseudarthrosis typically presents
as insidious back pain but can also be associated with acute
pain if the failure of bony union leads to implant fatigue. Bone
scans, multiple view static radiographs, dynamic radiographs,
and computed tomography (CT) scans with reconstructions
may all be used to potentially demonstrate a pseudarthrosis,
but none of these modalities are sufficiently accurate to rule
out the diagnosis. In addition to these, further imaging with
magnetic resonance imaging (MRI) or CT myelography to eval-
uate the neural elements may be indicated if dermatomal symp-
toms are reported, and blood work to evaluate for occult infec-
tion may also be necessary (e.g., CBC, erythrocyte sedimentation
rate [ESR], C-reactive protein [CRP]). Throughout the preop-
erative assessment for axial pain symptoms, the revision sur-
geon must remain suspicious for pseudarthrosis and occult
infection, as these need to be formally eliminated as diagnoses
before concluding that symptoms are due to symptomatic
implants.
Lower extremity radicular pain symptoms or symptoms of
neurogenic claudication may also be reported, particularly in
the setting of degeneration below previous long fusions. As
described for the axial pain symptoms, these complaints should
also be characterized for their timing of presentation with ref-
erence to the index procedure, rate of onset, and neurological
patterns suggesting etiology. Rapid-onset unilateral pain or
LWBK836_Ch93_p970-981.indd 972
weakness in a leg may indicate acutely herniated nucleus
pulposus, or failure if distal bone screw fixation and nerve root
trauma by unstable instrumentation.8,13 Gradual onset of uni-
lateral or bilateral leg pain, stenosis, or weakness in the setting
of a long fusion terminating in the midlumbar spine may indi-
cate degeneration below the fusion and symptomatic compres-
sion of the lumbar nerve roots or cauda equina. Evaluation
with standing full-length radiographs may demonstrate facet
arthrosis and loss of disc space height consistent with disc
degeneration with mild sagittal decompensation. Three-
dimensional imaging of the central canal and neuroforamen
with MRI or CT myelogram can be performed to evaluate the
neural elements. MRI is the study of choice if the prior
instrumentation was titanium, whereas CT myelography gives
the most reproducible information with stainless steel instru-
mentation.
Progressive spinal deformity in the previously operated adult
is typically due to either pseudarthrosis or junctional degenera-
tion. Patient complaints of falling forward, leaning to the
side, or frequent loss of balance may be due to loss of sagittal
or coronal balance. Additional observations may include height
loss, transverse abdominal crease, differences in clothing fit,
and increased rotational prominence in the thoracic or lumbar
regions. The deformity progression may be due to gradual and
progressive bending of the fusion mass in the setting of a weak
fusion or pseudarthrosis or due to degeneration of the motion
segment above or below the fusion mass (Fig. 93.1). Progressive
deformity is more likely to be symptomatic when degeneration
is present distal to the fusion mass rather than proximally10,13
and when positive sagittal imbalance is present.12,15,28 Flatback
syndrome is characterized by axial back pain symptoms, loss of
lumbar lordosis, and a positive sagittal decompensation.
Patients will often have pronounced hip and knee flexion while
in resting stance in an effort to balance their head and shoul-
ders over their pelvis and an exaggerated cervical lordosis to
provide a horizontal gaze for walking. Coronal balance is clini-
cally measured by using a plumb line from C7 to the gluteal
fold and can be used to monitor decompensation. Standing
sagittal balance is clinically estimated by viewing patient from
the side with knees locked in extension and visually evaluating
the relative sagittal position of the head and shoulders with
respect to the hips. Sagittal and coronal balance are also quan-
tifiable with full spine radiographs and vertical plumb lines
extended caudally from T1 to the posterosuperior S1 vertebral
body or center sacral vertebral line, respectively.
PREOPERATIVE CONSIDERATIONS
AND WORKUP
Special areas for emphasis during the evaluation should be
guided by the medical history of the patient, and information
must be gathered to determine how well the patient is medi-
cally optimized. Vital signs may demonstrate low-grade fever
consistent with indolent infection or poorly controlled high
blood pressure. Pulmonary auscultation may reveal wheezes,
rales, or rhonchi consistent with poorly controlled pulmonary
or cardiac disease. The trunk should be inspected for prior
incisions or other cutaneous findings if anterior surgery is
required for the revision reconstruction. Leg pain symptoms
require an evaluation of the hips and knees examination to
exclude intraarticular or other local pathology, and distal
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A B
C D
neurological and vascular examination must be completed to
document preoperative status. Neurological examination
should include evaluation of gait, light touch sensation, power
in all major muscle groups, reflex testing, and evaluation of
tension signs. Revision deformity surgery typically involves mul-
LWBK836_Ch93_p970-981.indd 973
Chapter 93 Revision Surgeries for Adult Spinal Deformity 973
Figure 93.2. An 18-year-old man with hemivertebra and
lumbar scoliosis and coronal imbalance who underwent ante-
rior spinal fusion that resulted in implant failure (panel
A, anteroposterior [AP] radiograph), instrumentation in the
canal (panel B, axial computed tomographic image, arrow,
indicates screw violation of canal), and progressive coronal
imbalance. He had partial removal of anterior implants, ante-
rior osteotomies and fusion to mobilize the deformity, and pos-
terior instrumented fusion (panel C, AP radiograph; panel
D, clinical photograph).
tiple hours of anesthesia and excessive blood loss is frequently
encountered, and it is necessary that a patient has sufficient
physiological reserve to tolerate the planned intervention.
Optimization of modifiable risk factors such as tobacco use
should be completed preoperatively, and postponement of
8/26/11 10:02:37 PM
 974 Section VIII Adult Spinal Deformity

A B D

Figure 93.3. A 58-year-old woman who

had T7-L3 posterior spine fusion with
Harrington instrumentation as a teenager
(panels A and B, anteroposterior [AP] and
lateral radiographs). She presented with flat-
back complaints of back pain, leg symptoms
consistent with stenosis, and myelogram/
computed tomographydemonstrated tight
stenosis at L4-5 and facet arthrosis (panels
C and D). She underwent same-day anterior
fusion from L3 to S1 and posterior instru-
mented fusion to the pelvis connecting to
the prior implants, with Smith-Peterson
osteotomies and decompression of the low
lumbar spine that resulted in restoration of
lumbar lordosis and sagittal balance (panels
E F
E and F, AP and lateral radiographs).

LWBK836_Ch93_p970-981.indd 974 8/26/11 10:02:38 PM


revision surgical intervention may be required if the patients
medical condition is insufficient.
Medical consultation is required to optimize the physiology
of the patient for the planned procedure and to provide risk
stratification or clearance for the operation. Medical preop-
erative assessments typically involve routine blood work,
anteroposterior (AP) and lateral chest radiographs, 12-lead
electrocardiogram, and transthoracic echocardiogram (for
men older than 40 years and women older than 50 years). If
revision surgery will involve thoracic spinal levels, then pulmo-
nary function testing is also obtained, along with pulmonary
medicine consultation if a thoracotomy is planned. Pertinent
findings from the history and physical examination, such as evi-
dence of infection or neurological abnormalities, should
prompt further diagnostic testing or specialty consultations. A
suspected infection should be evaluated with CBC with differ-
ential, ESR, and CRP to solidify the diagnosis and establish
baseline values. Suspected spinal infections may also be evalu-
ated with radionuclide bone scans (e.g., gallium scan to evalu-
ate tracer uptake) or CT scan to evaluate for localized fluid
collection. When wound infection is diagnosed, antibiotics
should be withheld until appropriate cultures and tissue biop-
sies can be obtained in the operating room, and infectious dis-
eases consultation should be considered when speciated cul-
tures and sensitivities are obtained.
Diagnostic imaging required preoperatively includes full
spine AP and lateral radiographs for every patient, and addi-
tional oblique or dynamic views as indicated. AP and lateral
images should be used to quantify residual deformity within the
previously fused segment, deformity present proximal or distal
to the fused segment, and radiographic coronal and sagittal
balance. Other parameters include shoulder asymmetry, pelvic
obliquity, proximal or distal junctional degeneration, and
assessment of vertebral rotation. A lateral hyperextension radio-
graph can be used to assess flexibility of regional kyphosis, and
AP bending films can be used to assess the flexibility of spinal
deformity in the coronal plane. Coned-down or oblique views
of the fusion mass and the previously described dynamic radio-
graphs may be useful to assess the fusion mass for pseudarthro-
sis (Fig. 93.2). CT scans with reconstructions can be used to
assess bridging trabecular bone between vertebrae if pseudart-
hrosis is suspected. If intervertebral disc status below the index
fusion is not able to be completed with standard imaging
modalities, then provocative discography may confirm disc
degeneration and concordant pain.
Patients with neurological findings or complaints that can
not be explained by three-dimensional imaging examinations
should prompt electrophysiologic testing to determine whether
the neurological deficits can be attributed to specific nerve
roots. Neurological consultation may be able to use preopera-
tive nerve conduction studies or electromyography (EMG) to
identify compromised nerve roots and guide surgery for
required decompression procedures. In cases requiring signifi-
cant deformity correction or spinal column shortening, thoracic
pedicle screw placement or use of implants placed within the
canal (e.g., hooks, wires) requires intraoperative spinal cord
1
List of abbreviations used in Algorithms 93.1 and 93.2: SX, symptoms; CBC, complete bood count, MRI, magnetic resonance imaging; ESR, erythrocyte sedimentation
rate; CRP, c-reactive protein; CT, computed tomography; I&D, irrigation and debridement; ID, infectious diseases, BX, biopsy; DJD, degenerative joint disease; RSD,
reflex sympathetic dystrophy; DX, diagnosis; SI, sacroiliac; EMG, electromyogram; NCV, nerve conduction velocity.
LWBK836_Ch93_p970-981.indd 975
Chapter 93 Revision Surgeries for Adult Spinal Deformity 975
monitoring with somatosensory evoked potentials, motor
evoked potentials, and EMG. Stagnara wake-up test must be per-
formed after the deformity correction and prior to completion
of the surgery if motor evoked potentials are not available.
In addition to intraoperative neuromonitoring, other con-
siderations for use in the operating room include use of a blood
salvaging system, and possibly staging the procedure. Means for
reducing blood loss during the operation including hypoten-
sive anesthesia, acute normovolemic hemodilution, and use of
blood salvaging systems such as the CellSaver should be dis-
cussed with the patient and anesthesia team prior to the day of
surgery. Patients may also wish to preoperatively donate and
store autologous units of blood or have directed donors donate
blood for the planned surgical procedure to limit their expo-
sure to banked blood stores. Discussions with patients should
also include the possibility of staging the procedure, if the
operation is to proceed for more than 10 hours of operative
time, if there is devastating neurological deficit, if patients
become hemodynamically unstable, or if bleeding during the
procedure should become excessive. Realistic estimates for
operative time, estimated blood loss, potential for neurological
injury, and other complications should be clearly explained
to patient and their families as regards the planned revision
procedure.
OPERATIVE INTERVENTIONS
After completing the preoperative assessments and deciding on
the definitive diagnosis, a plan for the revision surgery can be
designed (see Algorithms 93.1 and 93.2).1 As is the case for
primary deformity surgery, there are multiple surgical options
that are available to the revision surgeon, ranging from simple
extensions of previous fusions to complex and risky osteoto-
mies that should be attempted only by experienced surgeons.
In that the revision spine deformity population has already
undergone reconstruction, surgical options may be more lim-
ited in any particular patient, and overall complication rates
are quite high in this population. As a general rule, the smallest
magnitude and safest reconstruction option capable of correct-
ing the structural pathology should be chosen as the intended
procedure.
The simplest revision surgical interventions are those for
new relatively minor problems affecting a previously operated
spine. Examples include patients with painfully symptomatic
hardware without pseudarthrosis in need of instrumentation
removal or patients with deep spinal wound infections in the
setting of a healed fusion that require instrumentation removal,
irrigation and debridement of the wound, and antibiotics to
control the infection. Somewhat more complex problems
include infection in the setting of an early deep wound infec-
tion where fusion has not yet consolidated or an infection in an
established pseudarthrosis. In these cases, instrumentation is
required for stability and cannot easily be omitted. The surgical
plan requires irrigation and debridement of the wound, revi-
sion instrumented fusion, and long-term suppressive antibiotic
8/26/11 10:02:39 PM
 Pain as Chief Complaint

Superficial Deep Radicular

Related to Fever, weight loss, CT myelo or MRI

instrumentation? Constitutional SX? to evaluate roots

(+) () (+) ()
Trial of epidural
steroid injections
Consider injection Cutaneous process? CBC, ESR Evaluate for per imaging or as
of implants (cellulitis, myositis) CRP pseudarthrosis guided clinically
() (+) () (+) () (+) ()
()
Relief of SX?
(+) Gallium Revise Evaluate for Consider
I&D, Consider
(+) scan or fusion adjacent DJD decompression
CT fusion area to possible EMG/NCV
evaluate arthrodesis implant equivalent if revision and neurology
(+) () surgery is
removal consult
() required
(+) CT-guided (+) ()
biopsy Extend Assess
(Not fused)
(Fused) fusion balance in
Revise ()
Consider coronal and Management Obtain chronic
instrumented
removal of sagittal planes per consultant pain management
segment to Obtain ID
implants consult. Consider
obtain fusion consult,
consider dorsal column
open BX stimulator.
Medical
explanation? (Unacceptable) (Physiological)
(Shingles, RSD) Consider revision with Nonspine
or other spine DX? osteotomies to reason?
(SI joint, facet syndrome) restore balance

Algorithm 93.1.

Deformity as Chief Complaint

Coronal/Sagittal Balance Focal Deformity

Evaluate for Evidence for progression?

pseudarthrosis
(+) ()
(+) ()

Evaluate for Consider thoracoplasty

Revise fusion, Attempt rigorous pseudarthrosis if rib hump deformity, or
repair pseudos, physical therapy revision with osteotomies as
use osteotomies as for core strength (+) () needed to obtain correction
needed for correction and hip extension

Revise fusion, Progression must be through

Examine adjacent
repair pseudos, adjacent levels. Consider extending
levels for DJD and
use osteotomies fusion to include levels permitting
deformity
as needed for deformity. Use osteotomies as
(+) () correction indicated to obtain correction

Extend fusion to include Neurology consult

degenerate levels, with to evaluate possible
osteotomies as needed underlying etiology
to gain correction. Fusion (charcot, neuropathy)
to pelvis as required

Manage medical/neurology Dx.

Revise fusion to restore
balance with osteotomies
as needed for correction

Algorithm 93.2.
976

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TABLE 93.1 Comparison of Osteotomy Types
Smith-Petersen
Type
Correction per osteotomy 5 to 10
Dominant correction plane Sagittal
Average estimated blood loss Minimal
Neurological Minimal
complication rate
treatment. Intraoperatively, unattached bone graft materials
are removed from the wound, bone is prepared such that
healthy bleeding surfaces for fusion are in contact with one
another, and rigid fixation must be obtained. In cases of infec-
tions with continued sepsis despite repeated irrigation and deb-
ridements of the wound and appropriate parenteral antibiotics,
instrumentation may need to be removed despite the lack of
fusion and the patient placed in a fiberglass body cast with a
cutout to allow wound care. A thigh extension of the cast may
be indicated if immobilization of the low lumbar and lum-
bosacral vertebrae is required.
Other examples of new pathology affecting the previously
operated spine include adjacent-level degeneration proximal
or distal to a spinal deformity fusion. Degeneration proximal to
thoracic deformity fusions has been described to lead to proxi-
mal junctional kyphosis in 26% of patients at minimum 2-year
follow-up and mild pain symptoms that do not significantly
affect SRS-24 outcome scores.10 Coronal deformity is also
observed in patients with proximal junctional degeneration, is
less common than kyphosis deformity, and is similarly well tol-
erated clinically. Surgical intervention in patients with proxi-
mal segment degeneration may be indicated for intractable
pain symptoms, progressive deformity, or progressive neuro-
logical deficits attributable to the degenerated segment and
typically involve proximal extensions of the posterior instru-
mented fusion above the symptomatic segment and possibly
decompression of the level if stenosis is present. Conversely,
degeneration at segments distal to long fusions are observed in
up to 61% of patients, are frequently associated with debilitat-
ing symptoms, and correlate with inferior clinical outcomes
measures.7,8 Distal degeneration may be relatively mild with
pain generated by facet arthrosis or degenerative disc disease
that can be treated by extension of posterior fusion distally with
or without an associated interbody fusion at the distal segment
or can be more severe and associated with marked stenosis and
anterior sagittal decompensation as is often observed in patients
with flatback deformity. These latter patients are best managed
with decompressive procedures to manage the stenosis symp-
toms and revision deformity fusion and osteotomy procedures
designed to extend the index surgery to the pelvis while restor-
ing lumbar lordosis and physiologic sagittal balance. In all of
the varied revision deformity presentations, the goals are the
same: stable spine fusion, physiologic spine balance, minimal
residual symptoms, and functional restoration.6
Revision deformity surgery involving correction of spinal
alignment will almost invariably require use of vertebral
osteotomies.3 Osteotomies can be utilized to mobilize the
LWBK836_Ch93_p970-981.indd 977
Chapter 93 Revision Surgeries for Adult Spinal Deformity 977
Posterior Vertebral
Pedicle Subtraction Column Resection
30 to 35 40 to 45
Sagittal
Coronal or biplanar Multiplanar
correction with
asymmetric resection
1.8 to 7.8 L 0.8 to 7 L
11% to 25% 12% to 29%
spine and allow correction through flexible intervertebral
discs if these are not degenerate or previously fused as is done
with the Smith-Petersen osteotomy (SPO) or can be used to
create a bony transection of the spine, sparing the neural ele-
ments, for use as a site of direct realignment, as is done in the
pedicle subtraction osteotomy (PSO) and vertebral column
resection. We will briefly review the more commonly used
osteotomy procedures used in revision deformity surgery, with
emphasis on their logical application and clinical utility (see
Table 93.1). The most frequently used osteotomies was origi-
nally described by Smith-Petersen et al26 for use in sagittal
plane deformity correction in patients with rheumatoid arthri-
tis. Variations of the SPO have been described,6,14,17 but the
fundamental concept is for removal of a portion of the poste-
rior fusion mass leaving residual portions of fusion bone that
can be collapsed into apposition used to correct deformity.
Originally, the osteotomy was performed at one to three lev-
els, and involved a wide removal of the facets bilaterally, result-
ing in a chevron-shaped remnant of the posterior elements,
and dramatic anterior opening at the disc space anteriorly.26
More recently, multiple levels are osteotomized,28 fusion mass
bone removal is more variable,6 and dramatic anterior open-
ing of the disc space is avoided in effort to prevent visceral
and vascular complications (Fig. 93.3). An obvious limitation
of the SPO is that the anterior spine must have sufficient
mobility for correction after the posterior osteotomy is com-
pleted, making patients with very stiff degenerative spines, or
those with previous anterior fusions, poor candidates for this
technique. Since the bone is removed from the posterior col-
umn of the spine, there is a tendency for SPOs to cause lordo-
sis as the osteotomy sites are collapsed. Asymmetric SPOs in
the coronal plane can be generated to provide coronal cor-
rections, and symmetric SPOs can be used to restore lordosis
at an average of 5 to 10 of correction per level osteotomized.
Correction of gradual stiff deformity of moderate severity or
moderate decompensation (6 to 8 cm) is best attempted with
multiple-level SPOs as a first choice, due to their versatility
and relative safety.3
PSO is a very powerful technique for obtaining correction of
focal deformity and establishing spinal balance. The pedicle
subtraction osteotomy is alternately referred to as the egg-
shell osteotomy, the transpedicular decancellation osteotomy,
and the wedge osteotomy.4 The osteotomy involves removal of
a posteriorly based wedge-shaped segment of bone from the
spine and gets its name from the typical removal of the poste-
rior elements and pedicles of the osteotomized segment that
comprise the removed posterior wedge of bone. The surgical
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 978 Section VIII Adult Spinal Deformity
technique is completed entirely from a posterior approach, it
requires meticulous hemostasis to prevent excessive blood loss,
and care must be taken to prevent neurological deficit due to
the instability created during osteotomy. Pedicle screw fixation
is placed two to three levels proximally and distally to the level
to be osteotomized, the posterior elements are removed, and
nerve roots are identified and freed along their course in the
operative field. A provisional rod is placed during the osteot-
omy to prevent unintended movement of the spine, minimiz-
ing risk for neurological deficit postoperatively. The pedicles
are removed down to the level of the posterior vertebral body,
and cancellous bone within the vertebral body is either removed
or impacted proximally and distally within the vertebral body.
The size of the posterior vertebral body osteotomy required for
correction will have been determined preoperatively and will
serve to guide the osteotomies performed along the bilateral
sides of the vertebra that will complete the posterior wedge
resection. Ideally, the anterior cortex of the vertebral body will
not be osteotomized and will act as a hinge for the osteotomy
during posterior closure. The posterior wall of the vertebra is
removed last and completes the vertebral column transection.
Performing a symmetric posterior wedge resection will allow
correction in the sagittal plane, whereas creation of an asym-
metrically sized wedge can allow correction in both the coronal
and sagittal planes. The osteotomized bony surfaces are then
brought into apposition, deformity is reduced, and instrumen-
tation is secured. Typical corrections with standard PSOs are
30 to 35 per level, average blood loss ranges from 1.8 to 7.8 L,
and neurological complications were noted in 11% to 25% of
patients.5,18
Posterior vertebral column resection (PVCR) is the most
extreme posterior-only approach osteotomy that is currently
used by revision surgeons for severe and rigid spinal deformity.
This osteotomy involves a circumferential subperiosteal expo-
sure of the spine, removal of posterior elements and pedicles of
osteotomized levels, mobilization of nerve roots and neural ele-
ments, subtotal or complete removal of one or more vertebral
bodies and adjacent discs, and reconstruction with anterior
cages/grafts in combination with posterior instrumentation.
PVCR osteotomies performed in the thoracic region also
require resection of the proximal ribs of the osteotomized seg-
ments to obtain adequate exposure of the spinal column. The
PVCR osteotomy provides the most complete mobilization of
the spine for deformity correction in all planes and is useful for
deformities with very pronounced sagittal or coronal imbalance
or when translation of the osteotomy is required during the
deformity reduction. The surgical technique is largely similar
to that of the PSO described previously, with pedicle screw
instrumentation and temporary rod placement prior to initia-
tion of the osteotomy, but with much more bone resected dur-
ing the osteotomy procedure. Attempts should be made to pre-
serve the segmental nerve roots in the lumbar spine at the
levels of osteotomy, but this may not be possible in each case.
Nerve roots can safely be electively sacrificed in the thoracic
spine if this is required for completion of the anterior osteot-
omy. The anterior column may be reconstructed with a tita-
nium mesh or expandable cage and bone graft obtained from
the resected spine segment. Deformity corrections average 40
to 50 in the sagittal or coronal planes2,25,27,29 but have been
reported up to 100.2 Reported complications were encoun-
tered in 25% to 82% of patients in several series,2,27 neurologi-
cal complications occurred in 12% to 29% of patients,2,25 and
LWBK836_Ch93_p970-981.indd 978
average operative blood loss ranged from 0.8 to 7 L.27,29
Neurological complications ranged from epidural hematomas,
with resultant neurological complaints, to complete permanent
paralysis.
Combined anterior and posterior revision spine deformity
surgery is becoming less frequently utilized because of the ver-
satility of three-column posterior osteotomies. Indications
include gradual multilevel rigid deformity, pseudarthrosis or
malunion following posterior osteotomy, severe pelvic obliquity
or lumbosacral deformity, and patients requiring multiple-level
extension of proximal fusions to the sacropelvis. Anterior pro-
cedures include discectomies or end plate osteotomies for
mobilization of the stiff but unfused spine,28 osteotomies of
previously fused segments for correction and mobilization,12,28
and vertebrectomy for correction of severe deformities.
Posterior procedures include removal of previous instrumenta-
tion, evaluation for pseudarthrosis and repair as indicated, pos-
terior osteotomies of the previous fusion mass, and application
of revision instrumentation to support the indicated revision
fusion (Fig. 93.4). Final deformity after correction and compli-
cation rates are similar in patients receiving anteriorposterior
combined procedures in either primary or revision settings,
suggesting that revision surgical intervention is effective and
safe.9,16,19,21
COMPLICATIONS OF REVISION
DEFORMITY SURGERY
Despite obtaining deformity correction, physiological spine
balance, and solid arthrodesis of the fusion, residual pain is
frequently reported after revision deformity surgery. Cummine
et al6 reported in their series of 55 revision deformity surgery
recipients that 67% reported an improvement of their preop-
erative pain symptoms at average 3.3-year follow-up.6 Similar
rates of residual pain symptoms were reported at that time15,16
and in more recent patient series using third-generation pedi-
cle screwbased instrumentation systems.21,28 Interestingly,
despite report of continued pain symptoms, significant improve-
ments in standardized outcome measures are routinely observed
in patients after revision deformity correction.2,4,18,21,28 Specific
to correction of sagittal plane anterior decompensation in a
patient population composed of 90% patients who had previ-
ously undergone deformity correction, Ahn et al1 reported a
significant correlation in magnitude of sagittal angular correc-
tion and overall balance to outcomes measures for physical
function, vitality, and social function. Residual pain symptoms
may need to be anticipated in the postoperative period for
some revision deformity patients, but they should be counseled
that excellent clinical outcomes and improvement in function
can be expected.
Bleeding is a risk incurred by all patients undergoing sur-
gery. As described for each of the osteotomies previously,
requirement for inclusion of a vertebral osteotomy as part of
the revision deformity correction incurs risk for higher blood
loss during the surgery. This concept was directly shown by
Voos et al28 through comparison of patient populations obtain-
ing anterior discectomies with posterior osteotomies and
patients requiring anterior and posterior osteotomies.28 The
authors found significantly more bleeding in the group of
patients requiring anterior osteotomies than those receiving
discectomies anteriorly. Bleeding can be minimized through
8/26/11 10:02:40 PM
 Chapter 93 Revision Surgeries for Adult Spinal Deformity 979

A B D

Figure 93.4. A 36-year-old man who had undergone posterior spinal fusion for
kyphosis, had an infection and resultant removal of implants, and has progression of
kyphosis due to multiple-level pseudarthrosis (panel A, clinical photograph; panel B,
radiograph showing 87 of global kyphosis). Preoperative studies for indolent infection
were negative, and patient underwent same-day anterior spine releases and fusion and
posterior instrumented fusion to the pelvis with multiple-level Smith-Peterson osteotomies
(panel C, operative photograph) by utilizing a four-rod cantilever reduction maneuver
(panel D, operative photograph). Sagittal balance was restored postoperatively (panel
E F
E, clinical photograph; panel F, lateral radiograph).

use of thrombin-soaked Gelfoam on the osteotomy site, packing
of the wound to tamponade tissue seepage, and performing the
osteotomy as the terminal step of the procedure to minimize
the time that the bleeding bone surfaces are not in apposition.
Other interventions include use of a blood salvage system such
as the CellSaver, and anesthesia techniques including acute
normovolemic hemodilution, hypotensive anesthesia, and use
of amicar at the initiation of the surgery. Interestingly, in a
direct comparison of primary and revision deformity patients,
higher blood loss and transfusion requirement was observed in
patients undergoing primary corrections than revision sur-
gery.19 This result may be related to the higher average number
of levels fused in the primary fusion patients (n 18 vs. n 15
for revision) or potentially to the decreased decortication area
required for revision fusion of a smaller number of segments
within or appended to a previous fusion mass in contrast to the
primary fusion preparation that requires decortication of every
segment of the fusion bed.
Postoperative infections are another risk of any operative
procedure, although there is a general belief that longer opera-
tive times or larger blood loss during surgery, as would be
expected for revision spine deformity surgery, predisposes to
higher rates of wound infection. This concept of elevated risk
was not supported in a study that directly compared primary

LWBK836_Ch93_p970-981.indd 979 8/26/11 10:02:40 PM

 980 Section VIII Adult Spinal Deformity
and revision spine deformity patients, where although average
operative time was greater in the revision group (835 minutes
vs. 802 minutes for primary surgery), there was no difference in
postoperative wound infection rate (two were found in each
group, representing 7.8% to 11.1% of the patients).19 This rate
of wound infection in deformity surgery is within the range that
has been reported, with upper limit of 12% to 13%.21 The risk
concept was also not supported by a study comparing revision
spine deformity surgery with and without anterior osteotomies,
where patients receiving anterior spinal osteotomies had lon-
ger total operative times (626 minutes vs. 516 minutes for no
osteotomies) and greater average total blood loss (4599 mL vs.
2836 mL for no osteotomies), but no difference was observed
between groups for postoperative deep infections (none was
found in any of the 27 patients in the study). Patients should be
counseled that wound infection is a risk but that they require
revision spinal deformity surgery has not been demonstrated to
make them at greater risk than they had during their primary
deformity surgery.
Pseudarthrosis following revision spinal deformity surgery
has been reported to occur in 7.2% to 17.8% of patients in large
series.1,21 There are contradictory reports as to the effect of revi-
sion status on the risk for pseudarthrosis, with an initial study
concluding that revision surgery yielded fewer pseudarthroses16
and more recent studies describing no association9 or the oppo-
site effect.21 In an effort to limit pseudarthroses, anterior col-
umn supporting structural grafts are routinely used in the low
lumbar spine and lumbosacral junction, and rigid fixation is
applied posteriorly. Use of second-generation hook constructs
placed in compression to stabilize osteotomies used in revision
deformity surgery has been associated with a pseudarthrosis rate
of 38.2% and accompanied instrumentation problems of
18.2%.15 Studies assessing anchorage to the pelvis have shown
that LuqueGalveston fixation results in higher rates of pseu-
darthrosis than sacral or sacral/iliac combination fixation,9 solid
unilateral iliac fixation, and bilateral iliac fixation.21 For long
fusions to the sacrum, the authors prefer using anterior struc-
tural grafts in the low lumbar and lumbosacral levels, third-
generation pedicle screw constructs posteriorly when possible,
and anchorage to the pelvis with bilateral sacral screws supple-
mented with unilateral iliac fixation. Factors affecting decision
for bilateral iliac fixation include osteoporosis, poor bone pur-
chase with the initial iliac fixation, prior pseudarthrosis at L4-5
or L5-S1, and inability to place structural grafts anteriorly.
Instrumentation problems are reported in 8.4% to 20.4% of
revision spine deformity patients.1,9 Instrumentation problems
consist of implant breakage, loss of boneimplant fixation, and
painful/symptomatic instrumentation. Specific rates for each
of these problems vary, but painful instrumentation is relatively
frequent, having been reported in 7.2% to 20% of patients in
large series.1,21 Specific areas for painful implants are at the
proximal extent of the instrumentation, over the thoracic
kyphosis, and involving the iliac fixation.9,21 Implant breakage,
or loss of bone fixation, has been reported to affect 7.1% to
18.2% of patients,15,18 with suggestion for higher risk associated
with the use of second-generation spinal fixation15 and patients
with osteoporosis.12 Although bone cement augmentation of
instrumented vertebral bodies may help to prevent loss of
boneimplant fixation in osteoporotic patients, it has been
reported to potentially place the patient at risk for fat embo-
lism and would be expected to make revision of the cement-
augmented instrumentation very difficult to remove in the set-
LWBK836_Ch93_p970-981.indd 980
ting of infection, implant fracture, or required future revision.
The authors prefer to minimize symptomatic instrumentation
by using low-profile implants and 5.5-mm diameter rods in the
thoracic region and limit implantbone fixation problems by
using pedicle screws bilaterally at each level of the largest diam-
eter that will be accepted by the pedicle. Newly available ultras-
trength rods have promise to provide better fatigue-life of
implants and are expected to increase the probability that spi-
nal fusion will occur rather than implant failure. Other tech-
nologies being evaluated include several biological agents that
may help to improve or accelerate bone healing, including use
of the commercially available bone morphogenetic proteins
and small molecules affecting bone formation.
Neurological complications following revision spinal defor-
mity surgery are dictated by the procedures that are utilized
during the procedures, as discussed earlier. Overall, neurologi-
cal problems including weakness, spinal cord compression,
nerve root symptoms, epidural hematoma, and postoperative
cauda equina are reported in 5.6% to 12% of patients,1,9 but
there is no evidence to support higher rates in revision
surgery.19,21 In two large series,1 postoperative weakness was
present in 5.6% to 7.2% of patients, spinal cord compression in
2.4% of patients, and epidural hematoma or cauda equina in
1.1% to 1.2% of patients. Lumbar nerve root injury is also rela-
tively uncommon after deformity surgery, being estimated at
1.4% after primary surgery and 3.8% following revision surgery.
The authors prefer to minimize risk for permanent neurologi-
cal damage intraoperatively through use of somatosensory and
motor evoked potential neurophysiological monitoring that
can help to guide the surgeon away from hazards including
overzealous deformity correction and iatrogenic neural com-
pression. This method has been applied successfully in mini-
mizing potential neurological complications during spinal
deformity correction by using pedicle subtraction osteotomies.5
Stagnara wake-up testing to confirm voluntary movement of all
four extremities is also recommended before allowing the
patient to be transported from the operating room.
Deep venous thrombosis (DVT) and pulmonary embolus
(PE) are potentially devastating complications in the postoper-
ative setting. The reported rates for DVT and PE in recent large
series of adult spine deformity patients were 1.4% to 2% and
2% to 2.4%, respectively.21,23 Specific to anterior and posterior
combined surgery, Piasecki et al24 reported on a cohort of
66 patients screened postoperatively with Doppler ultrasound
examination of the legs and MRI venogram of the pelvis and
legs.24 They found DVTs in 9.1% of the group, PE in 7.6% of
the group, and an overall thromboembolic disease rate of
13.6%, with higher risk associated with higher intraoperative
blood loss and surgical approach from the right side. The
authors recommended postoperative prophylaxis against DVT
and PE with early mobilization, antiembolism stockings, sequen-
tial intermittent compression devices worn on the lower
extremities, and consideration of a preoperative retrievable
inferior vena cava filter in complex procedures planned
through a right-sided thoracoabdominal approach.24 Pateder
et al23 have reported on the results from their institution over
the period from 1992 to 2000, using mechanical and routine
chemoprophylaxis for DVT/PE in adult spine deformity
patients.23 They found higher prevalence of DVT/PE in patients
undergoing anterior approach surgery rather than posterior
surgery and more DVT/PEs in patients undergoing staged
anteriorposterior procedures than those done same day, and
8/26/11 10:02:42 PM

they confirmed that more DVT/PEs were found in patients
after right-sided anterior approach than left-sided approach.
They found that revision status, age, gender, operative blood
loss, procedure length, and the number of levels instrumented
did not alter DVT/PE rates. Interestingly, despite the routine
use of warfarin (Coumadin) or heparinoids postoperatively,
they incurred only two epidural hematomas (0.48%) requiring
decompression and one wound hematoma (0.24%). The rec-
ommendations from the study were that patients undergoing
anterior spine surgery, and particularly those receiving a right-
sided approach or staged surgery, should be considered candi-
dates for DVT/PE chemoprophylaxis; otherwise, all patients
should be managed with the standard mechanical DVT/PE
prophylaxis regimen of antiembolism stockings and sequential
intermittent compression devices.
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