BACKGROUND: Ankylosing spondylitis (AS) is an autoimmune spondylarthritis often associated with rigid kyphoscoliosis. The authors describe a surgical approach that employs multilevel three-column osteotomies for the restoration of normal global alignment.
METHODS: A 48-year-old male with a past medical history of AS presented to the clinic with a stooped-over posture: his chin-brow vertical angle (CBVA) was 58.0°; T1 slope (T1S), 97.8°; thoracic kyphosis (TK; T1-12), 94.2°; proximal TK (T1-5), 50.8°; distal TK (T5-12), 43.5°; and sagittal vertical axis (SVA), 22.6 cm. A two-stage procedure was planned. During stage 1, instrumentation was placed from C5 to T10, followed by a T3 vertebral column resection. During stage 2, bilateral pedicle screws were placed from T11 to the pelvis. An L3 pedicle subtraction osteotomy (PSO) was completed and was followed by a T7 PSO. Postoperatively, the patient had significant postural improvement: CBVA was 29.3°; T1S, 57.8°; TK, 77.3°; proximal TK, 33.5°; distal TK, 43.8°; and SVA, 15 cm. At 6 years postoperatively, the patient continued to do well and was without evidence of construct breakdown.
CONCLUSIONS: The authors propose that multilevel three-column osteotomies, if optimally located, successfully correct spinal malalignment associated with AS.

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UNASSIGNED: A high-angle thoracolumbar kyphotic deformity (TLKD) may complicate surgical rectification of AS patients since one-stage two-level pedicle subtraction osteotomy (PSO), which provides high-angular correction, leads to excessive blood loss, neurological deficits and fixation failures. This case series presents the long-term results of one-stage single level PSO with Ponte osteotomy (PO) in the treatment of AS patients with high-angle TLKD.
METHODS: This case series presents two AS patients with high kyphotic angles (KAs) of 86.1o. We collected data retrospectively from our institution\'s database between 2019 and 2023. A sagittal axis imbalance was the only complaint initially, no neurological deficits or other problems. A PSO augmented by PO was performed with a decompression laminectomy. Intraoperative monitoring (IOM) during reduction was used to observe neurological deficits. Blood loss at the highest rate was 1000 cc. It corrected 57.8o of KA postoperatively without neurological deficits. We found consistent results over 36 months.
UNASSIGNED: A thorough analytical approach may help diagnose AS. One-stage single-level PSO may correct high-angle TLKD in AS patients effectively. To achieve greater angular correction, PO, a less risky osteotomy, must be added. Decompression laminectomy is vital before osteotomy and IOM is crucial during reduction to prevent nerve injury. Even with two osteotomies, there was less blood loss than previously reported. These impressive long-term results call for further research.
CONCLUSIONS: Combined PSO and PO with IOM efficiently magnifies the angular correction without postoperative neurological deficits or excessive blood loss in AS patients with high-angle TLKD.

BACKGROUND: Neurological complications are higher in patients with severe spinal deformities (Cobb angle >100°). The authors highlight a known technique for thoracic concave apical pedicle resection that is useful for spinal cord decompression in patients with high-risk spinal deformities in the setting of intraoperative neuromonitoring (IONM) changes.
METHODS: A 14-year-old female with progressive idiopathic scoliosis presented for evaluation of her clinical deformity. Scoliosis radiographs showed a double major curve pattern comprising a 107° right main thoracic curve and a compensatory 88° left thoracolumbar curve. She underwent 2 weeks of halo-gravity traction that reduced her major thoracic curve to 72°. During thoracic posterior column osteotomies, the authors were alerted to decreases in IONM signals that were not responsive to increases in mean arterial pressure, traction weight reduction, and convex compression maneuvers. The dural surface was tightly draped over the two thoracic apical pedicles of T7 and T8, so emergent pediculectomies were performed at both levels for spinal cord decompression. IONM signals gradually improved and eventually became even better than baseline. The patient woke up without any neurological deficits.
CONCLUSIONS: Pediculectomy of the concave apical pedicle(s) should be considered for spinal cord decompression if there are IONM changes during high-risk spinal deformity surgery.

The objective of this study was to investigate the incidence and risk factors of rod fractures (RFs) after a single-level lumbar pedicle subtraction osteotomy (PSO) using a side-tightening (ST) pedicle screw system.
Fifty-seven consecutive patients who underwent a single-level lumbar PSO for the degenerative sagittal imbalance at a single institution were retrospectively reviewed. All surgeries were performed by a single surgeon using an ST pedicle screw system. Demographic, surgical, and radiographic data were analyzed to investigate the incidence and risk factors for RF.
Seven (12.3%) patients showed RF after PSO. Four patients had bilateral RFs, and 3 patients had unilateral RFs. The location of the RF was at the PSO level in 6 of 7 patients. The ratio of adjacent interbody fusion was significantly different between the group with RF and the group without RF (16.7% vs. 74.0%, P = 0.004). The preoperative segmental angle at the PSO vertebra (-6.1° ± 5.5° vs. -1.7° ± 4.6°, P = 0.049) and postsurgical change in lumbar lordosis (48.4° ± 8.8° vs. 37.8° ± 11.9°, P = 0.033) were significantly different between the 2 groups. Risk factor analysis using stepwise logistic regression analysis revealed that the absence of an adjacent interbody cage (odds ratio = 0.011, 95% confidence interval = 0.000-0.390, P = 0.013) was a significant risk factor.
The incidence of RF after a single-level lumbar PSO using the ST pedicle screw system was 12.3% in our cohort. The absence of an adjacent interbody cage was a significant risk factor for RF.

Lateral lumbar interbody fusion (LLIF) and pedicle subtraction osteotomy are common procedures to correct adult spinal deformities. Little is known about returning postoperatively to a high-performance sport such as skiing after spinal surgery. We report a case of an alpine skier who underwent a LLIF procedure combined with a posterior corrective osteotomy and posterior instrumentation, who had difficulties returning to skiing postoperatively because of new spinal biomechanics. The case report describes the possible consequences of spinal sagittal deformity surgery on postoperative skiing. A 63-year-old man with a complex lumbar spinal surgery history showed severe adjacent segment degenerative spondylolistheses at L1-L2 and at L5-S1. A lateral approach at L1-L2 combined with a posterior corrective osteotomy at L3 and instrumentation from T10 to the pelvis were performed. At his 1-year follow up, he made excellent progress and returned to skiing. However, he reported that skiing did not feel the same, and his center of gravity felt as if it shifted backwards. Consequently, he placed a 2-cm wedge in his ski binding, which improved his skiing experience. Sagittal vertical axis changes after spinal surgery affect the biomechanics of the entire body. After surgery, the body\'s ligaments, muscles, and fascia adapt to the new body posture. Activities such as skiing, where body posture plays an essential role, are particularly affected by spine surgeries. Surgeons should discuss this issue before spinal surgery with patients, especially if patients are involved in high-intensity sports.

Rigid and ankylosed thoracolumbar spinal deformities require three-column osteotomy (3CO) to achieve adequate correction. For severe and multiregional deformities, multilevel 3CO is required but its use and outcomes are rarely reported.
To describe the use of multilevel pedicle subtraction osteotomy (PSO) in adult spinal deformity (ASD) patients with severe, rigid, and ankylosed multiregional deformity.
Retrospective review of 5 ASD patients who underwent multilevel PSO for the correction of severe fixed deformity and review the literature regarding the use of multilevel PSO.
Five patients presented with spinal imbalance secondary to regional and multiregional spinal deformities involving the thoracolumbar spine. All patients underwent a single-stage two-level noncontiguous PSO, and 2 of the patients underwent a staged third PSO to treat deformity involving a separate spinal region. Significant radiographic correction was achieved with normalization of spinal alignment and parameters. Two-level PSO was able to provide greater than 80 degrees of sagittal plane correction in both the lumbar and thoracic spine. Two patients experienced new postoperative weakness which recovered to preoperative baseline at 3 to 6 mo follow-up. At most recent follow-up, 4 of the 5 patients gained significant pain relief and had improved functionality.
Noncontiguous multilevel PSO is a formidable surgical technique. Additional risk (compared to single-level 3CO) comes in the form of greater blood loss and higher risk for postoperative weakness. Nonetheless, multilevel PSO is feasible and effective for correcting severe multiplanar and multiregional ASD, and patients gain significant benefits in increased functionality and pain relief.

A number of spinal pathologies result in fusion of the spine, including ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis (DISH), as well as severe degenerative arthropathies. This fusion of spinal elements may result in spinal deformity affecting any region of the spine. Cervicothoracic deformity resulting in chin on chest deformity is poorly tolerated due to inability to maintain a horizontal gaze. Surgical treatment options for this condition are complex and require extensive discussion between the patient and surgical team. Here we present a case report of a 26-year-old transgender female (male to female) patient with severe chin on chest deformity and a unique pattern of spinal fusion involving only the posterior elements. She underwent C2-T8 posterior spinal fusion with thoracic pedicle subtraction osteotomy and multiple cervical facet osteotomies with good functional result. She did have severe dysphagia and required feeding tube for several weeks but did very well by 1 year postoperatively. While posterior elements of the spine are normally affected first in spondyloarthropathies such as ankylosing spondylitis, the lack of anterior spinal involvement is unique and could be attributed to hormonal therapy in this patient. This case describes a unique pattern of spondyloarthropathy and highlights the importance of a having a multi-disciplinary team for the treatment of patients with complex spinal pathologies.

BACKGROUND: Kyphosis secondary to pyogenic spondylodiscitis is rare and its management can be very challenging.
METHODS: In this report, we present the case of a 28-year-old woman, with past history of type 1 diabetes and kidney failure on hemodialysis. Her current complaint is chronic middle and low back pain with kyphotic attitude. She had undergone posterior fixation for T12 fracture 3 years earlier, which was complicated by surgical site infection to Pseudomonas aeruginosa, with secondary kyphosis proximally. X-ray showed a 64° kyphosis with complete fusion between T8 and T10, and MRI showed persistent infection foci.
RESULTS: The patient underwent a pedicle subtraction osteotomy at the level of T9 with instrumentation from T5 to L1. Thoracic kyphosis was corrected to 39°. Samples taken from the remaining collections returned positive for multidrug-resistant Pseudomonas aeruginosa, and the patient was kept on intravenous antibiotic (Colistine) for 2 months. She could walk on day 1, with a satisfactory clinical and radiological result at 3 years.
CONCLUSIONS: Literature is sparse on the management of post-pyogenic infection kyphosis in immunocompromised patients. The current case shows that aggressive correction techniques such as pedicle subtraction osteotomy can be performed in such cases but within a multidisciplinary team to deal simultaneously with the different issues of the fragile patient.

Rigid cervicothoracic kyphotic deformity (CTKD) remains a difficult pathology to treat, especially in the setting of prior cervical instrumentation and fusion. CTKD may result in chronic neck pain, difficulty maintaining horizontal gaze, and myelopathy. Prior studies have advocated for the use of C7 or T1 pedicle subtraction osteotomies (PSOs). However, these surgeries are fraught with danger and, most significantly, place the C7, C8, and/or T1 nerve roots at risk.
The authors retrospectively reviewed their experience with performing T2 PSO for the correction of rigid CTKD. Demographics collected included age, sex, details of prior cervical surgery, and coexisting conditions. Perioperative variables included levels decompressed, levels instrumented, estimated blood loss, length of surgery, length of stay, complications from surgery, and length of follow-up. Radiographic measurements included C2-7 sagittal vertical axis (SVA) correction, and changes in the cervicothoracic Cobb angle, lumbar lordosis, and C2-S1 SVA.
Four male patients were identified (age range 55-72 years). Three patients had undergone prior posterior cervical laminectomy and instrumented fusion and developed postsurgical kyphosis. All patients underwent T2 PSO: 2 patients received instrumentation at C2-T4, and 2 patients received instrumentation at C2-T5. The median C2-7 SVA correction was 3.85 cm (range 2.9-5.3 cm). The sagittal Cobb angle correction ranged from 27.8° to 37.6°. Notably, there were no neurological complications.
T2 PSO is a powerful correction technique for the treatment of rigid CTKD. Compared with C7 or T1 PSO, there is decreased risk of injury to intrinsic hand muscle innervators, and there is virtually no risk of vertebral artery injury. Laminectomy may also be safer, as there is less (or no) scar tissue from prior surgeries. Correction at this distal level may allow for a greater sagittal correction. The authors are optimistic that these findings will be corroborated in larger cohorts examining this challenging clinical entity.