Indications

• •
  

  Correction of multiplanar spinal deformity

  
  
• •
  

  Correction of fixed sagittal and coronal imbalance

  
  
• •
  

  Correctable imbalance through mobile segments

Contraindications

• •
  

  Spinal stenosis owing to risk of exacerbating stenosis during closure of osteotomy

  
  
• •
  

  Medical inability to tolerate surgery

Planning and positioning

• •
  

  Preoperative plain radiographs and computed tomography (CT) are obtained to evaluate sagittal and coronal imbalance, bone quality, and pedicle size and angle.

  
  
• •
  

  The patient is placed prone on a Jackson table to release abdominal contents from pressure, preventing epidural venous congestion and intraoperative blood loss.

  
  
• •
  

  It must be possible to provide extension of the spine and hips to close osteotomy sites.

  
  
• •
  

  If upper thoracic spine fixation is needed, the head must be fixed in a neutral position with a Mayfield head frame with the patient’s arms secured on the sides.

  
  
• •
  

  In mid-thoracic to lower thoracic spine and lumbar fixation procedures, the head does not need to be secured, and the arms are positioned at 90-degree angles above the head. The axilla is cushioned with foam pads.

  
  

  
  

  
  

  

  
  

  
  

  The Jackson table allows abdominal contents to hang freely, preventing epidural venous congestion and decreasing intraoperative blood loss.

  
  

Procedure

A standard midline incision is performed; the number of levels included in the osteotomy determines its length, keeping in mind that fixation points above and below osteotomy sites are needed. Subperiosteal dissection is performed using monopolar cautery to expose posterior elements, including the transverse processes. The posterior column including the spinous process, edges of the lamina, and ligamentum flavum are resected between the facet joints. Osteotomy is started at the interlaminar space. Resection is carried out laterally to the foraminal space, and both articular processes are excised.

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