Spine Deformity 6 (2018) 84e95

www.spine-deformity.org

Posterior-Only Vertebral Column Resection for Fused Spondyloptosis

Jeffrey L. Gum, MDa,b, Lawrence G. Lenke, MDc,*, Anand Mohapatra, MDd, Sam Q. Sun, MDc,
Michael P. Kelly, MDb
a
Norton Leatherman Spine Center, Louisville, KY 40202, USA
b
Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
c
The Spine Hospital, Department of Orthopedics, Columbia University Medical Center, New York City, NY USA
d
Washington University School of Medicine, St. Louis, MO 63110, USA
Received 27 May 2015; revised 17 May 2017; accepted 12 June 2017

Abstract
Study Design: Retrospective review.
Objectives: To describe 3 cases of a posterior-only vertebral column resection (pVCR) for the treatment of spondyloptosis in the setting of
prior spinal fusions.
Summary of Background Data: Lumbosacral spondyloptosis is a rare spinal deformity with a number of surgical options, none of which
demonstrate clear superiority. The use of an L5 vertebral column resection, via combined anterior and posterior approaches, to restore
lumbosacral alignment has been described though is accompanied by high rates of neurological deficit.
Methods: Review of 3 cases of spondyloptosis with prior spinal fusions in which a staged pVCR was used for deformity reconstruction.
Results: Three females, ages 39, 54, and 28, developed spondyloptosis with progressive lumbosacral kyphosis and sagittal malalignment
after prior in-situ posterolateral spinal fusions. All were treated with staged pVCRs. At ultimate follow-up, imaging revealed improvement
in sagittal balance of 6.1 cm (56%) in the 39-year-old and 12 cm (67%) in the 54-year-old, 21.1 cm (92%) in the 28-year-old. All patients
had improvement in outcome scores with perfect satisfaction scores despite the 54-year-old having a persistent right foot drop.
Conclusion: Posterior-only VCR for spondyloptosis is a technically demanding surgical option offering significant radiographic and
clinical improvement, but carries a risk for L5 nerve root deficit as in any spondyloptosis treatment.
Ó 2017 Scoliosis Research Society. All rights reserved.
Keywords: Spondyloptosis; Vertebral column resection

Introduction neurologic deficit [1-4]. A number of surgical options have

been described, including anterior and posterior approaches
Lumbosacral spondyloptosis is a rare spinal deformity
or all-posterior procedures, with no clearly superior tech-
that can be associated with pain, progressive deformity, and
nique [5-12]. The goal of surgery is safe and effective

Author disclosures: JLG (consultancy fees from Medtronic, LifeSpine,
Acuity, Corelink, Pacira Pharmaceuticals, PAKmed, Alphatec, Stryker, and
Gerson Lehrman Group; employee of Norton Healthcare; payment for lec-
tures including service on speakers bureaus from Medtronic and LifeSpine;
travel paid to institution by Medtronic during fellowship 2013-2014; and
travel paid to author during fellowship 2013-2014; fellowship support
2013-2014 from OREF and AO Spine; honorarium from Pacira, MiMedix,
and Alphatec); LGL (board membership [unpaid positions] in Backtalk,
Journal of Neurosurgery: Spine, Journal of Pediatric Orthopaedics, Jour-
nal of Spinal Disorders & Techniques, Scoliosis, Scoliosis Research Soci-
ety, Spine Deformity, Spine, The Spine Journal, www.iscoliosis.com, and
www.spineuniverse.com; consultancy fees [monies donated to a charitable
foundation] from DePuy Synthes Spine, K2M, and Medtronic; grants to
institution from AOSpine and Scoliosis Research Society, Axial Biotech,
DePuy Synthes Spine; payment for lectures including service on speakers
bureaus [monies donated to a charitable foundation] from DePuy Synthes
Spine and K2M; unpaid patents from Medtronic; royalties from Medtronic,
Quality Medical Publishing; travel expenses [reimbursement for airfare/-
hotel only] from AOSpine, BroadWater, DePuy Synthes Spine, K2M, Se-
attle Science Foundation, Scoliosis Research Society, Stryker Spine, The
Spinal Research Foundation; fellowship grant [institutional support for
fellowship] from AOSpine North America; philanthropic research funding
from Fox Family Foundation); AM (none); SQS (none); MPK (consultancy
fees from Advance Medical; grants to institution from OREF,
Barnes-Jewish Hospital Foundation, and AOSpine).
*Corresponding author. The Spine Hospital, Department of Orthope-
dics, Columbia University Medical Center, New York City, NY USA.
Tel.: (212) 932-4333; fax: (212) 932-5097
E-mail address: ll2989@columbia.edu (L.G. Lenke).

2212-134X/$ - see front matter Ó 2017 Scoliosis Research Society. All rights reserved.
http://dx.doi.org/10.1016/j.jspd.2017.06.002
 J.L. Gum et al. / Spine Deformity 6 (2018) 84e95
correction of the spinal deformity with decompression of
the lumbosacral nerve roots. The amount of reduction one
should attempt is the most debated technical portion of the
procedure [8,13,14]. With increasing amounts of trans-
lational reduction come higher rates of neurologic deficit,
most occurring with corrections exceeding 50% [15,16]. A
reasonable aim of surgery is elimination of lumbosacral
kyphosis and minimization of the translational element of
the spondylolisthesis. The use of an L5 vertebral column
resection (VCR), via combined anterior and posterior ap-
proaches, to restore lumbosacral alignment has been
described but is accompanied by high rates of neurologic
deficit [17,18]. The purpose of the study is to identify a
series of patients undergoing posterior-only VCR (pVCR)
for the treatment of spondyloptosis in the setting of prior
spinal fusions.
Materials and Methods
Using a prospectively collected adult spinal deformity
database, we retrospectively identified a consecutive series
of 3 patients who underwent pVCR for lumbosacral spon-
dyloptosis with previous arthrodesis from 2008 to 2012.
Patient 1
A 39-year-old female professor presented with wors-
ening lumbosacral pain, bilateral lower extremity radi-
culopathies, and progressive deformity. At age 14, the
patient had a traumatic spondylolisthesis at L6eS1. She
progressed to complete spondyloptosis and underwent an
L5eS1 in situ fusion at age 14 followed by a revision
L4eS1 in situ fusion at age 16. Her neurologic examination
was normal except for left extensor hallucis longus (EHL)
weakness (4/5). Standing posteroanterior (PA) and lateral
radiographs revealed six non-rib-bearing vertebral bodies
and a spondyloptosis of L6 on S1 (Fig. 1A). A lumbar
computed tomographic (CT) scan confirmed an arthrodesis
from L5 to S1, including an anterior spinal fusion at L6eS1
(Fig. 1B). The patient stood with a crouched stance in
positive sagittal alignment (Fig. 1C).
Patient 2
A 54-year-old female school teacher presented with
symptoms of lumbosacral pain, bilateral lower extremity
radiculopathies, and progressive deformity. The patient had
undergone 5 prior spinal surgeries, including Harrington
instrumentation from T11 to the sacrum, for progressive
spondylolisthesis with the first at age 13. Her neurologic
examination was normal. Standing PA and lateral radio-
graphs as well as her preoperative magnetic resonance
imaging and CT scan revealed an arthrodesis from T11 to
the sacrum (Fig. 2A and B). On examination, the patient
stood with a crouched stance and forward sagittal align-
ment (Fig. 2C).
85
Patient 3
A 28-year-old woman presented with progressive
deformity and bilateral lower extremity weakness and
numbness. At age 16 she had a posterior fusion for grade IV
spondylolisthesis that worsened following a car accident 5
years later. She underwent three subsequent revisions with
dural leak, instrumentation failure, and progression of her
deformity despite a solid posterior spinal fusion from L1 to
the sacrum. Standing PA and lateral radiographs and CT
scan with 3D reconstruction revealed an arthrodesis from
L4 to the sacrum (Fig. 3A and B). On examination, the
patient stood with a crouched stance and extreme forward
sagittal alignment (Fig. 3C). The neurologic examination
revealed grade 3/5 EHL, 4/5 tibialis anterior, and 4/5
quadriceps on the left and grade 4/5 EHL and tibialis
anterior on the right but was otherwise normal.
Results
Patient 1
The patient underwent a staged, pVCR of L6. During the
first stage, fusion exploration confirmed a fusion at L5eL6,
L6eS1, and a pseudarthrosis at L4eL5. A decompression
was performed via laminectomies at L5, L4, and the infe-
rior aspect of L3, with revision laminectomies at S1eS2.
Exiting nerve roots were identified and any dorsal scar
tissue removed to avoid buckling of the dura. Sacropelvic
fixation was achieved with six (three pairs) iliac screws
followed by placement of pedicle screws from L2 to S1. A
sacral dome osteotomy was performed to allow access to
the L6 vertebral body and to create a smooth plane for
docking of the proximal fusion mass with correction of the
translational deformity. Temporary rods were placed and
the wound closed. Neurologic monitoring via somatosen-
sory evoked potentials and electromyography pedicle screw
stimulation was without alerts. Total operative time was
482 minutes and estimated blood loss (EBL) was 3,000 mL
(50% estimated blood volume [EBV]).
The second-stage procedure was performed two days
later. With one temporary rod still in place, a posterior
column osteotomy was performed at L5eL6. The resection
of L6 was then performed below this osteotomy, by
resecting the L5eL6 disc and exposing the lateral portion
of the L6 body at the level of the pedicle on the left side,
similar to a PSO. Once the lateral body was exposed, the
pedicle was decancellated and the cortical bone was
removed. The anterior and lateral cortical bone of L6 was
thinned or ‘‘egg-shelled’’ with the combination of curettes
and a high-speed burr. The goal of the thinning process is to
leave just enough of a boney rim to avoid getting into any
extracavitary structures such as the segmental artery, but
thin enough to crumble or fracture the body under a gentle
compressive force. The temporary rods were switched and
the same resections were performed on the contralateral
side. The final lordotic rods were then engaged at the iliac
86 J.L. Gum et al. / Spine Deformity 6 (2018) 84e95

Fig. 1. (A) Preoperative PA and lateral radiographs of patient 1 showing grade V spondylolisthesis or spondyloptosis of L6 on S1. Three-year postoperative
PA and lateral radiographs showing improved lumbosacral alignment and sagittal vertical axis (C7 plumb). The reduction has been maintained with no ev-
idence of instrumentation loosening. (B) Midsagittal T2-weighted MRI and CT showing grade 5 spondylolisthesis with bridging bone between anterior S1
and posterior aspect of L6. Spine model made off of the 3D CT scan shows the fusion mass as well. (C) Posterior and lateral profiles of patient 1 taken
preoperatively and 3 years postoperatively. The lateral pictures show a dramatic improvement in sagittal alignment. CT, computed tomographic; MRI, mag-
netic resonance imaging; PA, posteroanterior.
 J.L. Gum et al. / Spine Deformity 6 (2018) 84e95 87

Fig. 2. (A) Preoperative PA and lateral radiographs showing spondyloptosis of L5 on S1 with severe positive sagittal malalignment (C7 plumb 18 cm). Two-
year postoperative PA and lateral radiographs show significant improvement in coronal and sagittal profiles. Noted is the asymptomatic rod fracture between
the right S1 screw and iliac screws due to sacroiliac joint motion. (B) Midsagittal MRI and postmyelogram CT scan. (C) Posterior and lateral clinical pictures
taken of patient 2 prior to the L5 pVCR and at 2 years postoperatively show dramatic improvement in sagittal alignment. CT, computed tomographic; MRI,
magnetic resonance imaging; PA, posteroanterior.
88 J.L. Gum et al. / Spine Deformity 6 (2018) 84e95

Fig. 3. (A) Preoperative PA and lateral radiographs showing spondyloptosis of L5 on S1 with severe positive sagittal malalignment (C7 plumb O23 cm).
She was likely stabilizing herself by holding onto bars for the radiographs as they do not show the amount of imbalance that her clinical photographs do. Two-
year postoperative PA and lateral radiographs show significant improvement in coronal and sagittal profiles. (B) Midsagittal CT scan and anterior/posterior
views of 3DCT showing posterolateral fusion from L2 to the sacrum with internal bone stimulator. (C) Posterior and lateral clinical pictures taken of patient 3
prior to the L5 pVCR and at 2 years postoperation show dramatic improvement in her forward stance and sagittal alignment. Note on the second preoperative
lateral picture that she is only able to get herself in a more upright position by bending her knees. (Clinical pictures were sized so legs are approximately the
same length to emphasize her preoperative stance.) CT, computed tomographic; MRI, magnetic resonance imaging; PA, posteroanterior.
 J.L. Gum et al. / Spine Deformity 6 (2018) 84e95 89

Table 1
Patient-reported outcome scores.
SRS domains Pain Self-image Function Satisfaction Mental health Average score* ODI score
(pre/po) (pre/po) (pre/po) (pre/po) (pre/po) (pre/po) (pre/po)
Patient 1 2.6/4.4 1.8/4.3 3.4/4.4 2.0/5.0 3.2/3.6 2.8/4.2 36/6
Patient 2 2.2/3.0 1.7/4.2 2.4/3.4 2.0/5.0 3.0/3.0 2.3/3.4 23/15
Patient 3 1.0/1.5 1.2/3.5 1.4/1.8 1.0/5.0 2.8/2.4 1.6/2.3 66/44
ODI, Oswestry Disability Index; pre, preoperative; po, postoperative; SRS, Scoliosis Research Society.
*
Does not include satisfaction domain.

screws and sacral screws, and the rods were then reduced to
the cranial lumbar reduction screws. This action flexed the
sacrum while providing correction of the lumbosacral
kyphosis and the pelvic tilt. The correction of the trans-
lational component of the deformity was performed via
slow (1-2 hours) reduction of the lumbar screws to the rods.
The tension on the nerve roots was checked with each in-
cremental correction, every 1 to 2 mm. An intraoperative
Stagnara wake-up test was performed along with somato-
sensory evoked potentials and direct nerve root stimulation
to ensure that no neurologic deficit had been created with
the reduction. Total operative time and EBL for the second
stage were 282 minutes and 1,400 mL (23% EBV),
respectively.
The patient was discharged from the hospital on day
10. At her 3-year follow-up, her Oswestry Disability Index
and SRS-22R scores were both improved, with a perfect 5
in the satisfaction domain (Table 1). Most recent radio-
graphs (Fig. 1) and clinical pictures (Fig. 3) show
improvement in her alignment and radiographic parame-
ters (Table 2).
Patient 2
The patient underwent a planned staged pVCR of L5.
The first stage confirmed an arthrodesis from T11 to L1 and
L2 to the sacrum with a pseudarthrosis at L1eL2. A
decompression was performed via laminectomies at
L4eS2. Bilateral iliac fixation was achieved with 6 (3
pairs) iliac screws. Pedicle screws were placed from T12 to
the sacrum, excluding L5. The pedicles of L5 were resec-
ted, as well as the dorsal elements from the pedicles of L4
to S1 in preparation for the VCR at L5. Temporary rods
were then placed. Somatosensory evoked potentials,
transcranial motor evoked potentials, pedicle screw stimu-
lation, and intraoperative electromyographs were utilized
for spinal cord and nerve root monitoring without alerts.
Operative time was 451 minutes, and EBL was 2,500 mL
(64% EBV) for the first stage.
The second-stage procedure was performed 4 days later.
With one temporary rod in place, an extracavitary approach
was used to resect the remaining L5 body and the L4eL5
disc with a similar decancellation and cortical thinning
technique described above in patient 1. A sacral dome
osteotomy was performed after resecting L5. This allowed
the dorsal aspect of S1 to function as a retractor of the thecal
sac, keeping it out of the way during the resection of L5. A
similar rod reduction technique as previously described was
used. During the correction, tension of the right-sided nerve
roots was appreciated. Direct nerve root stimulation was
performed at 2.0 milliamperes for the right and under 1.0 for
the left. An intraoperative wake-up test was then performed
showing weak ankle dorsiflexion on the right. The construct
was then taken apart and the correction decreased, thereby
decreasing the tension on the right L5 and S1 roots. The
transcranial motor evoked potentials to the right foot
increased when this was done. Direct palpation confirmed
that minimal tension was present. A second wake-up test
after closure in the operating room revealed that the patient
had no active dorsiflexion of her right ankle. For the second
stage, operative time and EBL were 365 minutes and 2,000
mL (51% EBV), respectively.
Postoperatively, the patient was found to have a right
foot drop. This was still present at her 2-year follow-up
although her Oswestry Disability Index and SRS-22R
scores were still both improved, with a perfect 5 in the
satisfaction domain (Table 1). At her 2-year postoperative
follow-up, her radiographs (Fig. 2A) and clinical pictures
(Fig. 2C) show improved balance and radiographic pa-
rameters (Table 2).
Patient 3
The patient underwent a planned, staged pVCR of L5
with a partial S1 corpectomy. The first stage confirmed an

Table 2
Pre- and postoperative radiographic parameters.
Patient SVA (cm) (pre/po) SA (
) (pre/po) PI (
) (pre/po) PT (
) (pre/po) LL (
) (pre/po)
Patient 1 þ10.8/þ4.7 30/20 85/85 52/37 106/65
Patient 2 þ18/þ6 41/6 81/81 63/45 89/42
Patient 3 þ23/þ1.9 38/17 72/72 37/31 33/55
LL, lumbar lordosis; PI, pelvic incidence; po, postoperative; pre, preoperative; PT, pelvic tilt; SA, slip angle; SVA, sagittal vertical axis.
90 J.L. Gum et al. / Spine Deformity 6 (2018) 84e95

Fig. 4. The cauda equina sac is protected and gently retracted medially along with the S1 root, to allow for sacral dome excision. This is done bilaterally and
separately protecting the L5 roots as well.

arthrodesis from L2 to the sacrum. A revision decompres-
sion was performed via laminectomies at L4eS2. Iliac
fixation and neuromonitoring were performed similar to the
previous cases. Operative time was 547 minutes, and EBL
was 3,000 mL (76% EBV) for the first stage.
The second-stage procedure was performed three days
later. She had improvement in her left foot dorsiflexion (4/5
EHL). Very similar to the previous cases, an extracavitary
approach was used to resect the remaining L5 body and the
L4eL5 disc with sacral dome osteotomy. During the
correction, tension of the right-sided nerve roots was
appreciated. An intraoperative wake-up test was then per-
formed showing good dorsi- and plantarflexion. For the
second stage, operative time and EBL were 187 minutes
and 1,100 mL (28% EBV), respectively.
Postoperatively, the patient was found to have
improvement in bilateral dorsiflexion. At 2-year follow-up,
her Oswestry Disability Index and SRS-22R scores were
both improved, with a perfect 5 in the satisfaction domain
(Table 1). Most recent radiographs (Fig. 3A) and clinical
 J.L. Gum et al. / Spine Deformity 6 (2018) 84e95 91

Fig. 5. While the central sac, L5 and S1 roots are protected and carefully retracted, the L5 pedicles and vertebral body are then resected. The pedicles are
removed directly and the body decancellated, also thinning down the anterior body with a power burr as is seen.

pictures (Fig. 3C) show improved balance and radiographic
parameters (Table 2). Figures 4e8 are illustrations of the
various steps of this pVCR technique.
Discussion
Spondyloptosis is a rare spinal deformity and may be
associated with high morbidity [1-4]. The natural history of
untreated spondyloptosis is unclear as it occurs infrequently
and the majority of studies group it with lower-grade
spondylolistheses [18]. Surgical management is techni-
cally challenging, particularly if greater reduction of the
deformity is attempted. Although in situ fusion has been
described, it does not address the focal kyphosis that is the
primary driver of the progression of slip severity and
overall deformity. Reports of slip progression in the setting
of a confirmed arthrodesis after in situ fusion and kyphosis
undercorrection highlight the importance of kyphosis
correction [7,19]. Additionally, if the kyphosis is left un-
treated, tremendous shear stress at the fusion site is present,
92 J.L. Gum et al. / Spine Deformity 6 (2018) 84e95

Fig. 6. Correction of the deformity occurs with a unilateral rod, with the sacrum/pelvis translated ventrally while the L4 and more cephalad lumbar segments
are pulled dorsally, and also compressed to shorten the spinal column.

which contributes to the high pseudarthrosis rate [19,20].
Potential benefits of reduction include direct canal and
foraminal decompression, correction of the lumbosacral
focal kyphosis, and increased fusion rates with less tension
on the fusion mass. Additionally, the improvement in the
lumbosacral kyphosis also helps explain the improvement
in the global alignment observed in our case series. Several
authors have reported on the high rate of neurologic com-
plications associated with reduction with permanent deficits
occurring in as much as 21% to 31% of cases [5,9,18,21].
The majority of the strain on the L5 nerve roots (71%)
occurs in the last half of the reduction, making complete
reduction particularly dangerous to these roots [16]. Stretch
injuries to the cauda equina have been reported as well,
again emphasizing the highly complex nature of manage-
ment of spondyloptosis [17,22].
To reduce the strain on the neural elements, spinal
shortening procedures have been described [17]. Gaines
and Nichols first described and popularized the use of an L5
vertebrectomy through a combined anterior and posterior
approach [12]. A subsequent review by Gaines in 2005 of
30 cases over a 25-year period utilizing the same technique
revealed a high rate of transient L5 root deficits (22/30,
77%), with two permanent deficits [17]. Modifications of
the technique described by Gaines have been reported by
others, but only as case reports with typically poor results
 J.L. Gum et al. / Spine Deformity 6 (2018) 84e95 93

Fig. 7. A structural cage is then placed into the anterior defect between L4 cephalad and S1 caudad. The cage is placed between the L5 and S1 roots
unilaterally.

[22,23]. Only one prior case report described an L5 verte-
brectomy in the setting of a prior fusion and described a
staged anterior-posterior procedure. This was complicated
by both L5 nerve root and cauda equina deficits [22].
Overall, the literature describing a VCR is scarce but
consistent with a high complication rate. The staging nature
of the procedures allows for the case to be broken up into
physiologically manageable segments. The goal of the first
stage is always to remove previous fixation points, place
new fixation, and perform posterior decompression and/or
releases with provisional rods. The second stage is focused
toward the anterior resection and reduction. One downfall
to staging is the elevated blood loss. When the second stage
is reopened, there is inevitably a hematoma that we have
included in the EBL calculations that has artificially
elevated the estimation to an extent. The extremely high
EBL for this series is also a reflection of the complexity of
the cases.
To our knowledge, this article is the first to describe
posterior-only VCRs for the treatment of lumbosacral
spondyloptosis in patients with previous fusions. All
patients had a minimum follow-up of 2 years; ideally these
94 J.L. Gum et al. / Spine Deformity 6 (2018) 84e95

Fig. 8. The final correction is obtained with bilateral compression of the construct from L4 to the sacrum, which simultaneously finishes the correction of the
deformity and locks in the structural cage between L4 and the sacrum.

complex patients would be followed much longer.
Despite diligent efforts to minimize the risk of neurologic
deficit, using intraoperative neurologic monitoring
and intraoperative wakeup tests, one patient sustained a
neurologic deficit. These results emphasize the overall
risk associated with the surgical management of spondy-
loptosis, whether an ‘‘all posterior’’ approach or a com-
bined anterior and posterior procedure is used. Overall,
all three patients benefited from the procedure, as evi-
denced by the improvement in outcome scores. Each of the
patients described reported a 5, the highest possible score,
in the satisfaction domain of the SRS-22 instrument, which
emphasizes the benefit of the surgery for the patients.
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