Abstract
Introduction
Treatment of spine imbalance by posterior osteotomy is a valuable technique. Several surgical techniques have been developed and proposed to redress the vertebral column in harmonious kyphosis in order to recreate correct sagittal alignment. Although surgical techniques proved to be adequate, preoperative planning still is mediocre. Multiple suggestions have been proposed, from cutting tracing paper to ingenious mathematical formulas and computerised models. The analysis of the pelvic parameters to try to recover the initial shape of the spine before the spine imbalance occurred is very important to avoid mistakes during the osteotomy planification.
Material and method
The authors proposed their method for the osteotomy planning paying attention to the pelvic, and spine parameters and in accordance with Roussouly’s classification. The pre operative planning is based on a full-body X-ray including the spine from C1 to the femoral head and the first 10 cm of the femur shaft. Using all the balance parameters provided, a formula name FBI is proposed. Calculation of the osteotomy is basic goniometry, the midpoint of the C7 inferior plateau (point a) is transposed horizontally on the projected future C7 plumb line (point b) crossing posterior S1 plateau on a sagittal X-ray. These are the first two reference points. A third reference point is made on the anterior wall of the selected vertebra for osteotomy at mid height of the pedicle (point c) mainly L4 vertebra. These three points form a triangle with the tip being the third reference point. The angle represented by this triangle is the theoretical angle of the osteotomy. Two more angles should be measured and eventually added. The femur angulation measured as the inclination of the femoral axis to the vertical. And a third angle named the compensatory pelvic tilt to integrate the type of pelvis. If the pelvic tilt is between 15 and 25° or is higher than 25° you must add 5 or 10°, respectively. This compensatory tilt is based on a clinical analysis of operated patients.
Results
This planification was applied in a retrospective study of 18 patients and showed why in some cases improper correction was performed and prospectively in 8 cases with good clinical outcomes and correct spinal alignment. Sometimes it is necessary to find an acceptable compromise when rebalancing the spine paying attention to the general parameters of the patients like: age, osteoporosis, systemic disease etc.
Conclusion
This FBI technique can be used even for small lordosis restoration: it gave a good evaluation of the amount of correction needed and then the surgeon had the choice to use the appropriate technique to obtain a good balance.
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References
Aurouer N, Obeid I, Gille O, Pointillart V, Vital JM (2009) Computerized preoperative planning for correction of sagittal deformity of the spine. Surg Radiol Anat, Jul 14. [Epub ahead of print]
Bridwell KH, Lewis SJ, Edwards C, Lenke LG, Iffrig TM, Berra A, Baldus C, Blanke K (2003) Complications and outcomes of pedicle subtraction osteotomies for fixed sagittal imbalance. Spine (Phila Pa 1976) 28(18):2093–2101
Bridwell KH, Lewis SJ, Lenke LG, Baldus C, Blanke K (2003) Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance. J Bone Joint Surg Am 85-A(3):454–463
Bridwell KH, Lewis SJ, Rinella A, Lenke LG, Baldus C, Blanke K (2004) Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance. Surgical technique. J Bone Joint Surg Am 86-A(Suppl 1):44–50
Burton DC (2006) Smith-Petersen osteotomy of the spine. Instr Course Lect 55:577–582
Caputy AJ, Spence CA, Bejjani GK, Luessenhop AJ (1997) The role of spinal fusion in surgery for lumbar spinal stenosis: a review. Neurosurg Focus 3(2):e3 discussion 1 p following e4
Chiffolot X, Lemaire JP, Bogorin I, Steib JP (2006) Pedicle closing-wedge osteotomy for the treatment of fixed sagittal imbalance. Rev Chir Orthop Reparatrice Appar Mot 92(3):257–265
Debarge R, Demey G, Roussouly P (2010) Radiological analysis of ankylosing spondylitis patients with sever kyphosis before and after pedicle substraction osteotomy. Eur Spine J 19:65–70
Dubousset J, Charpak G, Skalli W, Kalifa G, Lazennec JY (2007) EOS stereo-radiography system: whole-body simultaneous anteroposterior and lateral radiographs with very low radiation dose. Rev Chir Orthop Reparatrice Appar Mot 93(6 Suppl):141–143
Gill JB, Levin A, Burd T, Longley M (2008) Corrective osteotomies in spine surgery. J Bone Joint Surg Am 90(11):2509–2520
Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F (2005) The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976) 30(18):2024–2029
Ikenaga M, Shikata J, Takemoto M, Tanaka C (2005) Clinical outcomes and complications after pedicle subtraction osteotomy for correction of thoracolumbar kyphosis. J Neurosurg Spine 6(4):330–336
Jang JS, Lee SH, Min JH, Kim SK, Han KM, Maeng DH (2007) Surgical treatment of failed back surgery syndrome due to sagittal imbalance. Spine (Phila Pa 1976) 32(26):3081–3087
Joseph SA Jr, Moreno AP, Brandoff J, Casden AC, Kuflik P, Neuwirth MG (2009) Sagittal plane deformity in the adult patient. J Am Acad Orthop Surg 17(6):378–388
Kiaer T, Gehrchen M (2010) Transpedicular closed wedge osteotomy in ankylosing spondylitis: results of surgical treatment and prospective outcome analysis. Eur Spine J 19:57–64
Kim YJ, Bridwell KH, Lenke LG, Cheh G, Baldus C (2007) Results of lumbar pedicle subtraction osteotomies for fixed sagittal imbalance: a minimum 5 year follow-up study. Spine (Phila Pa 1976) 32(20):2189–2197
Kim YJ, Bridwell KH, Lenke LG, Rhim S, Cheh G (2006) Sagittal thoracic decompensation following long adult lumbar spinal instrumentation and fusion to L5 or S1: causes, prevalence, and risk factor analysis. Spine (Phila Pa 1976) 31(20):2359–2366
Legaye J, Duval-Beaupère G, Hecquet J et al (1998) Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves. Eur Spine J 7:99–103
Leijssen P, Duarte M, Aunoble S, Fisher E, Le Huec JC (2010) Posterior wedge osteotomy for imbalance spine new method of evaluation: FBI technique. Eur Spine J 19(Suppl 3):S233–S364
Lovejoy CO (2005) The natural history of human gait and posture. Part 2. Hip and thigh. Gait Posture 21(1):113–124
Murrey DB, Brigham CD, Kiebzak GM, Finger F, Chewning SJ (2002) Transpedicular decompression and pedicle subtraction osteotomy (eggshell procedure): a retrospective review of 59 patients. Spine (Phila Pa 1976) 27(21):2338–2345
Ondra SL, Marzouk S, Koski T, Silva F, Salehi S (2006) Mathematical calculation of pedicle subtraction osteotomy size to allow precision correction of fixed sagittal deformity. Spine (Phila Pa 1976) 31(25):E973–E979
Rose PS, Bridwell KH, Lenke LG, Cronen GA, Mulconrey DS, Buchowski JM, Kim YJ (2009) Role of pelvic incidence, thoracic kyphosis, and patient factors on sagittal plane correction following pedicle subtraction osteotomy. Spine (Phila Pa 1976) 34(8):785–791
Roussouly P, Gollogly S, Berthonnaud E, Dimnet J (2005) Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine (Phila Pa 1976) 30(3):346–353
Scudese VA, Calabro JJ (1963) Vertebral Wedge Osteotomy. Correction of Rheumatoid (Ankylosing) Spondylitis. Jama 186:627–631
Tai CL, Hsieh PH, Chen WP, Chen LH, Chen WJ, Lai PL (2008) Biomechanical comparison of lumbar spine instability between laminectomy and bilateral laminotomy for spinal stenosis syndrome—an experimental study in porcine model. BMC Musculoskelet Disord 9:84
van Royen BJ, Scheerder FJ, Jansen E, Smit TH (2007) ASKyphoplan: a program for deformity planning in ankylosing spondylitis. Eur Spine J 16(9):1445–1449
Vosse D, van der Heijde D, Landewe R, Geusens P, Mielants H, Dougados M, van der Linden S (2006) Determinants of hyperkyphosis in patients with ankylosing spondylitis. Ann Rheum Dis 65(6):770–774
Yang BP, Chen LA, Ondra SL (2008) A novel mathematical model of the sagittal spine: application to pedicle subtraction osteotomy for correction of fixed sagittal deformity. Spine J 8(2):359–366
Yang BP, Ondra SL, Chen LA, Jung HS, Koski TR, Salehi SA (2006) Clinical and radiographic outcomes of thoracic and lumbar pedicle subtraction osteotomy for fixed sagittal imbalance. J Neurosurg Spine 5(1):9–17
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Le Huec, J.C., Leijssen, P., Duarte, M. et al. Thoracolumbar imbalance analysis for osteotomy planification using a new method: FBI technique. Eur Spine J 20 (Suppl 5), 669 (2011). https://doi.org/10.1007/s00586-011-1935-y
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DOI: https://doi.org/10.1007/s00586-011-1935-y