All right, so I'm going to show some implants and things today, but that shouldn't be relevant. None of these are company-specific. So spinal deformity, we know. It's an ever-increasing part of our practices. You're here to learn about scoliosis and kyphosis. Some of these slides are redundant, but I do that on purpose. Recognizing the deformity before you can treat it is the key, and then we start trying to figure out, well, what's the deformity and how are we going to go about treating that? And right again, I put this up yesterday. Is there scoliosis, listhesis, kyphosis? What's the balance, coronal, sagittal? What is the pelvic parameter? Start there. Every time you're looking at something, start with those principles. Try and figure out what you're dealing with, and then you can figure out how best to treat it. And I always talk about, I have various talks on the various steps to correct a deformity. Well, yesterday we talked about balance. Today we're going to talk about releasing the spine and correcting the deformity, and a little bit on assessing the patient's flexibility. So when you start talking about correcting the spine and flexibility of deformity, flexibility is a relative term, right? We can make anything flexible with the right osteotomy. But to do any of these, you have to get good fixation. And we all did thoracic pedicle screws in the lab yesterday. And sometimes they're easy, sometimes they're hard. And in scoliotic patients, the pedicles aren't these nice, straightforward, reasonably sized pedicles sometimes. And you get a patient that comes in looking like this. This is an adult neuromuscular patient, a patient with cerebral palsy that has a really highly rotated curve. She's rotated, if you look, almost so her spine is touching her iliac crest. She's significantly maligned, both coronally and sagittally. And this is a screw going in to her. And if you think about sort of the angles you put screws in, and if you look at the angle that this screw goes in, right, if that was a normal patient, I'd be putting that right through the spinal canal. That's a fairly medialized screw when you're looking. Oh, sure. If I can get this to work. So you all got to see that screw going down there. So that's a rotated spine that's highly medialized. But if you look at that CT scan, that's the pedicle that screw went down. There's not much there to put that down. And you can see the significant rotation on that spine to get that through. So you have to be really confident with your anatomy. And if you can't get fixation in the spine, it gets really hard to correct it no matter how flexible it is. And there's her pre-op, her on table, and then her post-op film. You can see I put a third rod across there because I was worried about the amount of strain and the bend I had to put on some of those rods to get her there. But if you can get fixation on the spine, even though that was a pretty stiff neuromuscular curve, it comes around. So spinal balance, I'm not going to spend much time on that since we did so much yesterday. So we know alignment's important. Then how do we correct it? Well, you have to assess the flexibility, which we'll talk about. You have to get flexibility if you don't have it. Then you have to apply forces to the spine. And you're applying forces not really to the spine, but your implants. And that's how you really do this, whether it's compression, distraction, translation, derotation. We'll talk a little bit about that. So the instantaneous axis of rotation is a concept you just really need to understand. It's the point in space that the spine is going to rotate around when you apply force. That's all that is. So we're always trying to improve sagittal alignment, which is almost always adding lordosis or reducing kyphosis. So that is usually shortening the posterior column. In anterior cervical discectomy fusion, you oftentimes lengthen the anterior column by little incremental things. And it's really useful. And you saw yesterday some anterior surgeries that can definitely do that. So there is some lengthening, but oftentimes we're talking about posterior shortening. And just remember that instantaneous axis of rotation changes as you apply differing forces. And it's a three-dimensional world. You're not just thinking about sagittal plane, but it's a three-dimensional deformity. So it's going to rotate in the coronal and axial planes as well. So the most common way to do that is a Smith-Peterson osteotomy, which, again, we got to practice in the lab. Small posterior segmental osteotomies using that IAR to correct the spine. It's removing the interspinous ligament, lamina facet. And I know we're going to learn about osteotomy, so I'm not going to talk a whole lot about this. But that's a view of what it should look like. We did that in the lab yesterday. And the key is there so that frame is widely open at the end. That tip of that superior facet is not in there to compress down against that nerve when you correct the spine. You can make your own axis of rotation, which is exactly what a pedicle subtraction osteotomy is, is making a point at the front of that spine around which you're going to rotate. We did that. If you didn't do it in the lab yesterday, you can do that today. At my table, we did one yesterday. So we did exactly this. You make that apex at the front of the spine and have it look just like this at the end. And I won't belabor the steps here, but you're essentially trying to get a spine where you're going to pivot on that anterior cortex. That is your axis of rotation. It looks easy when you do it like this, but when you have the dura and the nerves and everything else in your way, it gets a little trickier, which we all know. So if the spine is previously fused, you've got a fixed spine. It's really easy to calculate the correction, all the trig that we talk about sometimes. You can plan an osteotomy if you need 30 degrees. You give it 30 degrees. It works out great. You're dead on. And I showed this case yesterday, again, how I calculate that by calculating the SVA, pelvic incidence, pelvic tilt. How much do you need? You add it all up, and you can correct that. So this is a fixed deformity everywhere except the bottom. And I used the only flexible disc she had to give some correction and then made my own flexibility with a pedicle subtraction osteotomy through the other site. And again, it looks like that. So if your spine is mobile, if it's really loose, if it's an adolescent neopathic and it moves around, you don't really need to do much. You do a little, you know, the Schwab grade one osteotomy. You take a little facet release, put some screws in. You can compress, distract, derotate. It works really well. It's fairly easy. The stiffer the spine, the more you have to work to get it mobile, and the harder you have to pull on your implants, and that's your limiting force sometimes. How much force can you put on the implants? Sometimes that's how good a fixation point you've got. Sometimes that's how bad the patient's bone is, and so that's where you really need to think about it. And some of the corrective forces, we use translation maneuvers. I use a lot in adult deformity. In adult degenerative lumbar scoliosis, I've changed my way. I used to put the convexity rod in first and really cantilever it down and push the spine around. I'm now doing a couple translation derotation as technology changes. People use reduction screws, and now you have these segmental reducers you can put on for most implants. I installed some that were out there you can play with where you can incrementally translate and do a couple translation derotation with the rod. Here's a view of what that looks like. This is a patient with a thoracic curve. Implants are all in. If we look, the rod's in down here in the lumbar screws. In the top, I've got it clipped right here, so I've got it captured in the upper screws, and I'm putting all these segmental reducers on several of the sites along the apex of that curvature. What I'm going to do is, there's a long throw in here. It acts like a reduction screw. I'm capturing the rod, which is probably 15, 20 millimeters away from that screw, and sequentially you're going to dial each one of those down, and it's going to bring that spine over as long as your fixation points are good enough. If you've got weak screws in here and they won't hold, you're going to do that, and they're all going to pull right out, and you didn't do anything, and now you don't have fixation, and you're going to do an in situ type fusion. But I've got one of the residents holding the rod here. If you see my hand here, I'm pushing those up, so this is where it's a little bit of a coupled maneuver. So I'm dialing these down, and I'm going to go each of those, and I'm trying to get the spine to not only shift over, but derotate a little bit, so I'm getting it to come up, and if I let these flop down, it's going to pull over. If I hold them up, it's going to kind of have to come up to those a little bit, so it's a little bit of a coupled translation derotation, and you can see you just go one, and then the other, and the other, back and forth, and back and forth, sharing that load across multiple implants. I'm not going to pull out any one screw and bringing that across. You can see as I go each way, I'm pulling it a little bit more. I'm pushing it a little bit more as it tightens down, trying to get that to derotate. Now, if you do that with a fixed head screw, it works really well, or a mono-axial screw, a screw that only rotates in the sagittal plane. If you use a poly-axial screw, it makes it easier to do this, but you lose some of that ability to that coupled translation derotation, and then tightening set screws, and we don't need to watch the rest of it. So after I do that, and I'm going to show you the same case, so after I do that maneuver, it's better. It's not perfect, and you're not trying to get it perfect. You're trying to get it balanced and stable and all of those good things, but I do some in-situ contouring. In-situ contouring is using benders in the rods. You have to be careful. Every time you bend a rod, you potentially weaken it a little bit, so you have to be thoughtful about that. Usually, you do all these maneuvers, and I sort of loosen the set screws a little bit so the rod can translate through there a little bit, and it's a good final maneuver. Some people do a sagittal in-situ bending with the set screws already in. I'm not a big fan because that really loads a lot of strain on your top implants, but coronal bending you can do pretty easily. And here's a view of what that looks like. So I'm trying to bring the spine from right to left, so I'm just going in just a little bit. You can see it's not a big maneuver. It's multiple little moves over many segments, just getting it a little bit better, a little bit better, a little bit better, and then you can go do compression distraction several rounds, a little bit better, a little bit better, a little bit better, and if you do that, and it takes 10 minutes or so to go and do it again and again and again, but it really makes for a nice correction, and that's how if you want those Larry Linky looking really nicely straight x-rays, that's what you need to do. So I went and spent some time with him watching it, and it is like 10 rounds of compression and distraction. It's over and over and over, but a little bit at a time goes a long way. If you try and get it all at once, you don't get that viscoelastic sort of relaxation of the tissues. You move it a little bit, the tissues relax a little bit more, you get a little bit more and a little bit more and a little bit more, and it ends up being fairly straight at the end. So before we do this, we need to assess is this a flexible, is this an inflexible curve, and I'm going to show you a few different patients that are all in the same age group. They're all in the later 60s, females with various curves and various flexibilities. So here's a patient. This is not a scoliosis. This is a sagittal plane issue. So this patient came in, had this. I don't know if you can see that there, but it is a grade 4 listhesis in the mid-lumbar spine, and it's not a... She didn't develop this on her own. She got a lot of help from some surgeons. So they did a laminectomy infusion and saw their implants are starting to loosen. So what do you do if your screws are loosening? You take them out, right? Then they don't loosen anymore. But, yeah, no, that is not the answer. You do not just take them out and assume it's going to be fine because it's not fine, and this is a huge problem. She's significantly maligned. That is a nightmare to fix. It's going to be a ball of scar. Nerves are going to be stretched. It's going to be torture until I get a CT scan and I look at this and I'm like, oh, that's not so bad anymore. She went from a grade 4 to a grade 2 here just by laying down for the CT. Now I know this is... It's moving on its own. If it moves on its own even a little bit, I know I can move it in surgery. And so I take her and do a fairly straightforward operation, just reduce that, do a T-lift, and I look like a hero. It looks great. She's happy. She's one of my happiest patients. She was completely disabled, back to work, and everything's good. It's like the ultimate success story. And everybody thinks, oh, wow, that was really great. And it wasn't even that hard because it just came back. I just had to do a little bit more release, a little bit of pull, some good screws, and get it to heal, which in a patient with a pseudo is an issue, but that works out really well. So here's a patient. Like I said, all these patients are going to be in their late 60s, female. So this is a pretty good curve. This lady is one that walks in and, you know, so my waiting room is kind of a funny place, but people look like this, and they come in. But when people look like this in the waiting room, all the other people are like, oh, I'm not so bad. This is not so bad. And because she's walking on the hall like really bad. Anytime their ribs start to overlap or inside or outside of the pelvis, usually people start to curve and their ribs hit their pelvis. And you're like, this rib's on hip pain, but it kind of stops there. When it starts to tuck in or out, it's a bigger problem. And she's saggedly way off. So that's a big problem until I get a supine x-ray. Look at her supine on the lateral x-ray and look at her curve where her ribs used to overlap her pelvis. Look at the space I have there. Now I know I'm going to look like a hero on this one again, because this moves on its own. If it moves on its own, I'm going to put her under anesthetic, put her on the table. It's going to line up. I'm going to do some maneuvers. I'm going to do some releases further and get it to come around. But now all I need to do is get it appropriately realigned, do a good job of getting good implants. And you can see her side bending films showing that this is even more flexible. Look at how nicely that bends out there. And in the end, she gets a operation that looks pretty good. She lines up really well. It looks really straight. She walks around. She's, you know, bringing in pictures of her before and after and everybody's happy and, and, and it's great. And you can see the progression here of crazy deformity. Not so bad, really not bad at all, to highly abnormal because she's got a lot of screws in her, but straight. And saggily, the same thing. Grossly mal-aligned, supina comes out, and then post-op it looks pretty good. Maybe a little hyper lordotic actually, but she actually hasn't P.J.K'd. She looks great. She stands up really well. Here's another one, another lady. Not quite as badly, but, but fairly badly deformed. A little more of an angular degenerative type curvature here. A kyphoscoliosis, so a little bit trickier there. Her supine films, it doesn't really budge. This is a stuck issue, right? I put her over a bolster. She's got a bolster behind her here. She's laying over it. People hate those films. I love them. If you just tell them to just lay there for five minutes, all I need is five minutes and they can never make it five minutes, so they gotta shoot it, but it doesn't move. So this is a stiff deformity. So I know going in, this is gonna be a harder day for me. I have to work harder on the releases. I have to really make sure I get some good screws, and I'm gonna have to accept a little bit less good correction. I don't need it to be straight. I just need it to be balanced, and with a little bit of work, it still ends up looking pretty decent here. I stopped at T10, which, you know, she's got a little thoracic kyphosis here. I cemented the top, which is off-label for that, but trying to minimize the risk of P.J.K., and fortunately we've gotten away with that so far. I tell all my people, if I can stop at T10, I'm gonna stop at T10. If you go to T4, you're sort of looking at increasing your pseudo rate. You stop at T10, you're looking at increasing your P.J.K. rate. I think the operation from a T10 going up to T2 to T4 as a revision isn't so bad, and it's really like a second stage operation if we need to, and so I rolled those dice, and here we got away with it quite nicely. Another lady, a bigger curve. This is an adult idiopathic curvature. Again, kyphoscoliotic and the kyphosis is through that thracolumbar junction, so stopping at T10 is not gonna be a great issue for me. Her bending films, maybe a little bit, but not a lot, and I look at her CT scan, and she's got all these osteophytes there anteriorly, so my choice is can I go and do a bunch of lateral approaches and break through osteophytes, and I can, but I think that's a little overkill. I don't think I need to do that to get her back the line. You can see her lateral listhesis here. I do wanna get that pulled over, and it's this fractional curve that's pretty stiff here. That's what I have to worry about. I have to get that to tip over every bit as much as I get this to pull over. If I don't do that, I'm not gonna get her back to balanced, and I accept a little less correction on her. You can see she's nicely balanced. She's nicely aligned in the sagittal plane. She's nicely, or in the sagittal and coronal plane, but you can see these screws are coming over here for a reason. The spine still goes over there. My rods look nice and straight, and everybody focuses on the rods, but she's still got some scoliosis there. She's well balanced. She's very happy, and again, if you look where her ribs used to be up on her hips, she's got this huge space here now, so it works out well, but I know going in what I have to do. I have to work harder the less flexible the patient is on their own, and I'm a believer. I look at the CT. If I see a vacuum disc, I'm in good shape. I look at the supine all the time. Side bending really is helpful in planning what my day is going to be like, and then I'm trying to figure out what do I want this to look like at the end, and I'm very happy with this x-ray. I think it looks great. It's exactly what I was thinking. You sort of walk in with your plan. What do you want it to look like? That's exactly what I wanted it to look like, and she's done well with that. Trying to get this completely straight by doing a bunch of anterior releases and everything else is completely overkill in my mind. It doesn't matter to her functionally at all. We just need her balanced and stable and without any root compression, so conclusion, you always have to look at the balance. You have to plan out these corrections. You have to have a plan when you go in. You have to be thinking how flexible is this? What levels am I fusing? What forces am I going to apply? What kind of implants do I need for that? Osteotomies are sort of the real workhorse of adult deformity, and my mantra is always SPOs when possible, PSO when necessary. All of these cases, other than that one PSO, are all Smith-Peterson or Ponte-style osteotomies, and flexibility really is the key. If you evaluate the flexibility, you can figure out what you need to do from a surgical treatment option standpoint, and that is it. Thank you.

spine deformity

treatment options

recognizing deformity

implants and osteotomies

spinal balance and stability