Lumbar Posterior Column Osteotomy and Correction
Mathew Cyriac
John M. Rhee
Illustrative Case
A 47-year-old man who underwent several previous surgeries elsewhere resulting in a solid fusion from L3 to S1 in hypolordosis. He complained of low back and bilateral leg pain thought to be related to adjacent segment stenosis at L2-3 (Figures 28-1 and 28-2).
 Figure 28-1 ▪ A-C, Preoperative x-rays show loss of lumbar lordosis and moderately positive sagittal vertical axis =13 cm. Close-up lumbar lateral x-ray demonstrates lumbar lordosis = 24°, solid fusion from L3-S1, and pelvic incidence = 60°. |
 Figure 28-2 ▪ T2 sagittal and axial MRI at L2-3 disk level showing central and lateral recess stenosis. The operative goals were decompression of the stenotic segment and extension of fusion in order to improve the presenting complaints of back and leg pain. In addition, given that he would have a relatively long segment fusion from L2-S1, it was desirable to improve overall sagittal balance rather than simply propagating the hypolordotic fusion more proximally. |
Indications/Considerations
Posterior column osteotomy (PCO) is a chevron resection of the lamina, ligamentum flavum, facets, and pars. The pars and the facets are removed such that the exiting roots are completely freed up from the caudal surface of the pedicle above to the superior aspect of the pedicle below. By compressing the posterior elements and shortening the posterior column, lordosis can be increased.
The primary indication for PCO is to increase lordosis. It can be done through previously fused or unfused segments.
It can be a posterior-only procedure (as in Figure 28-3) or performed in combination with an anterior release or osteoclasis of a fused disk space (eg, in ankylosing spondylitis).
Figure 28-3 ▪ (A, B) Area of bone resection when performing posterior column osteotomy. The disk may be left intact (C), undergo osteoclasis (D; eg, ankylosing spondylitis), or released and fused anteriorly (E).
Figure 28-3 ▪ (continued)
When associated with anterior release or osteoclasis, significantly more correction can be achieved.
However, doing so will lengthen the anterior column and potentially stretch the anterior great vessels.
When combined with an anterior release, the spine may become highly unstable. Therefore, rigid fixation is needed to prevent instrumentation failure.
More modest amounts of lordosis will be achieved when the disk is left intact, and the posterior column is shortened without lengthening the anterior column.Related posts:
Cervical Subaxial Laminectomy, Instrumentation, and Fusion (C3 to Upper Thoracic)
Percutaneous Thoracic Fusion and Pedicle Screw Instrumentation
Microdiskectomy
Minimally Invasive Transforaminal Lumbar Interbody Fusion
Airway Complications After Anterior Cervical Diskectomy and Fusion/Cricothyrotomy
Operative Treatment of Hangman’s Fractures
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