Operative Technique

A, After the posterior spine has been stripped of its paraspinal muscles, Ponte osteotomies can be completed either before or after pedicle screws are placed. The author prefers to perform the osteotomies after the screw tracts have been prepared for placement of screws to limit exposure to the spinal canal during the preparation of screws. The spinous processes are first partially excised with a Leksell rongeur. The ligamentum flavum is excised in the central most aspect until epidural fat is seen. A Kerrison rongeur is then used to remove the remaining ligamentum flavum as well as the superior and inferior articular facets. An alternative step is to perform inferior facetectomies in the normal method using a Capener gouge or straight osteotomies.

B, A side view of the spine demonstrating an intact spine (left) and following Ponte osteotomies at all levels (right). Note the ability for these osteotomies to allow the spine to close posteriorly by hinging on the anterior and middle columns of the spine.