For patients with flexibility of the disc spaces, a series of posterior column osteotomies can achieve significant deformity correction. In the realm of open surgery, these osteotomies are typically described as a Smith Peterson or Ponte osteotomy. The essence of the technique involves removal of sufficient spinous process, lamina, and facet bone to allow compression posteriorly between pedicle screws with the axis of sagittal rotation centered on the posterior vertebral body. This stretches the anterior longitudinal ligament and expands the anterior disc.

A single-level osteotomy will yield between 3° and 5° of lordosis. As such, posterior column osteotomies would typically be performed at three or more consecutive vertebral levels and can be used in the thoracic and/or lumbar spine. Since the adult population typically presents with scoliosis or kyphoscoliosis, these osteotomies would preferentially be compressed on the convexity of a scoliosis. An open surgery allows for bilateral osteotomies in the thoracic and/or lumbar spine. For minimal access surgery, no option yet exists for thoracic posterior column osteotomies. However, in the lumbar spine multilevel MIS TLIF, surgery can achieve unilateral facetectomies. When combined with interbody height restoration, this approach can lead to meaningful deformity correction, even in a rigid spine (Figs. 22.1 and 22.2).