Posterior Spinal Instrumentation: Scoliosis

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SAMPLE EXCERPT
- Full procedure text, video and illustrations available with the full product
PRE-PROCEDURE
INDICATIONS
  • Adolescent idiopathic scoliosis
  • Neuromuscular scoliosis
  • Scheuermann's disease
CONTRAINDICATIONS
  • General medical condition that increases the surgical anesthesia risk
  • Significant skin disorder overlying the incision area
  • Local or systemic infection
  • Severe pedicle hypoplasia
EQUIPMENT
  • Jackson table/frame
  • Epinephrine solution (1:500,000)
  • Weitlaner retractors
  • Electrocautery
  • Cobb elevators
  • Pedicle hooks
  • Curets
  • Pituitary rongeur
  • Pedicle finder
  • Pedicle inserter and holder
  • Pediculotransverse claw system
  • Transverse process elevator
  • Hook holder
  • Laminar hook system
  • Kerrison rongeurs
  • CD Horizon Legacy Spinal Deformity system
  • French bender
  • Beale rod reducer
  • Translator rod pusher
  • Counter-torque instrument
  • Break off driver
  • Obturator
  • Power burr/high speed burr
  • Cobb gouge
  • Thoracic gearshift probe
  • Pedicle screws
  • Fluoroscopy
  • Flexible ball-tipped probe
  • FloSeal
  • Fixed angle or multi-axial screwdriver
  • Forceps rocker
  • Electromyography
  • Rod reducer
  • Screw derotators
  • Iliac or pedicle probe
  • Pedicular transverse process claws
  • Reduction crimps
  • Long post pedicle screws
ANATOMY
  • Posterior superficial muscles: trapezius, rhomboid major, rhomboid minor, and latissimus dorsi.
  • The cartilaginous apophyses of the spinous processes (i.e., cartilaginous caps) are split to allow subperiosteal dissection of the spinous processes, laminae, facet joints, and transverse processes.
  • The laminae move out away from the spinous process and cranially in the direction of the transverse processes.
  • The facet joints of the thoracic spine are arranged in the coronal plane, whereas those of the lumbar spine are arranged in the sagittal plane.
  • Pedicle anatomy:
    • Connects the posterior elements to the vertebral body
    • Medial to the pedicle are the epidural space, nerve root, and dural sac.
    • The exiting nerve root at the level of the pedicle is close to the medial and caudal cortex of the pedicle.
    • Close to the lateral and superior aspects of the pedicle cortex is the nerve root from the level above.
    • At the L3 and L4 vertebral bodies, the common iliac artery and veins lie directly anterior to the pedicles.
  • The sacral region
    • The great vessels and their branches lie laterally along the sacral ala.
    • In the midline of the sacrum, a variable middle sacral artery can lie directly anterior to the S1 vertebral body.

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
TECHNIQUES
  • Post-Procedure: Pedicle Hook Implantation
  • Post-Procedure: Transverse Process Hook Implantation
  • Post-Procedure: Laminar Hook Implantation
  • Post-Procedure: Instrumentation Sequence in Typical Lenke IA Curve
  • Post-Procedure: Thoracic Pedicle Screw Insertion Techniques
  • Post-Procedure: Iliac Fixation with Iliac Screws
  • Post-Procedure: Posterior Multihook and Screw Segmental Instrumentation (Crandall)
  • Post-Procedure: Posterior Column Shortening Procedure for Scheuermann's Kyphosis (Ponte)

Post-Procedure: Pedicle Hook Implantation

POST-PROCEDURE CARE
  • Restrict oral intake until bowel sounds are heard and monitor for an ileus.
  • Administer intravenous antibiotics for 48 hours after surgery.
  • Use "pulmonary toilet" and incentive spirometer to minimize atelectasis.
  • Use an anesthesia pump and/or oral pain medication to control postoperative pain.
  • Remove the Hemovac drain after 24 to 48 hours.
  • Mobilize the patient from the bed to a chair as soon as pain allows.
  • A brace is usually not necessary.
  • Discharge from hospital when oral intake is tolerated, temperature normalizes, and the patient is independent.
  • May shower at 2 weeks post-op but limit lifting and heavy exertion for 6 months.
  • Advise against future contact sports.
COMPLICATIONS
  • Neurologic injury
  • Infection (less than 1%)
  • Ileus
  • Atelectasis
  • Pneumothorax
  • Dural tear
  • Wrong level surgery
  • Urinary complications
  • Pseudarthorosis
  • Loss of lumbar lordosis
  • Crankshaft phenomenon
  • Superior mesenteric artery syndrome
  • Trunk decompensation
ANALYSIS OF RESULTS

The newer segmental fixation devices for the correction of spinal deformities from a posterior approach have a high rate of success with a low rate of complications.

OUTCOMES AND EVIDENCE
  • Hamill et al: Pedicle screws improved coronal and sagittal correction and had better restoration of segmental lordosis than hook configuration.
  • Barr et al: Pedicle screws provided greater lumbar curve correction, better maintenance of correction, and greater correction of the uninstrumented spine below double major curves when compared with hook configurations.
  • Suk et al: Hook fixation resulted in 55% correction compared to 72% with thoracic pedicle screws. Pedicle screws had a 3% malposition rate on radiographs.
  • Luhmann et al: Thoracic posterior-only pedicle screw constructs provided equal correction to hook constructs with anterior release.
  • Kim et al: Better curve correction without neurologic problems, improved pulmonary function, and shorter fusion length with posterior pedicle screw instrumentation compared to segmental hook instrumentation.
  • Liljenqvist et al: 25% of pedicle screws penetrated the pedicle cortex or anterior vertebral body cortex on CT scan, most clinically relevant in the thoracic spine.
Procedure: Pedicle Hook Implantation

Post-Procedure: Transverse Process Hook Implantation

POST-PROCEDURE CARE
  • Restrict oral intake until bowel sounds are heard and monitor for an ileus.
  • Administer intravenous antibiotics for 48 hours after surgery.
  • Use "pulmonary toilet" and incentive spirometer to minimize atelectasis.
  • Use an anesthesia pump and/or oral pain medication to control postoperative pain.
  • Remove the Hemovac drain after 24 to 48 hours.
  • Mobilize the patient from the bed to a chair as soon as pain allows.
  • A brace is usually not necessary.
  • Discharge from hospital when oral intake is tolerated, temperature normalizes, and the patient is independent.
  • May shower at 2 weeks post-op but limit lifting and heavy exertion for 6 months.
  • Advise against future contact sports.
COMPLICATIONS
  • Neurologic injury
  • Infection (less than 1%)
  • Ileus
  • Atelectasis
  • Pneumothorax
  • Dural tear
  • Wrong level surgery
  • Urinary complications
  • Pseudarthorosis
  • Loss of lumbar lordosis
  • Crankshaft phenomenon
  • Superior mesenteric artery syndrome
  • Trunk decompensation
ANALYSIS OF RESULTS

The newer segmental fixation devices for the correction of spinal deformities from a posterior approach have a high rate of success with a low rate of complications.

OUTCOMES AND EVIDENCE
  • Hamill et al: Pedicle screws improved coronal and sagittal correction and had better restoration of segmental lordosis than hook configuration.
  • Barr et al: Pedicle screws provided greater lumbar curve correction, better maintenance of correction, and greater correction of the uninstrumented spine below double major curves when compared with hook configurations.
  • Suk et al: Hook fixation resulted in 55% correction compared to 72% with thoracic pedicle screws. Pedicle screws had a 3% malposition rate on radiographs.
  • Luhmann et al: Thoracic posterior-only pedicle screw constructs provided equal correction to hook constructs with anterior release.
  • Kim et al: Better curve correction without neurologic problems, improved pulmonary function, and shorter fusion length with posterior pedicle screw instrumentation compared to segmental hook instrumentation.
  • Liljenqvist et al: 25% of pedicle screws penetrated the pedicle cortex or anterior vertebral body cortex on CT scan, most clinically relevant in the thoracic spine.
Procedure: Transverse Process Hook Implantation

Post-Procedure: Laminar Hook Implantation

POST-PROCEDURE CARE
  • Restrict oral intake until bowel sounds are heard and monitor for an ileus.
  • Administer intravenous antibiotics for 48 hours after surgery.
  • Use "pulmonary toilet" and incentive spirometer to minimize atelectasis.
  • Use an anesthesia pump and/or oral pain medication to control postoperative pain.
  • Remove the Hemovac drain after 24 to 48 hours.
  • Mobilize the patient from the bed to a chair as soon as pain allows.
  • A brace is usually not necessary.
  • Discharge from hospital when oral intake is tolerated, temperature normalizes, and the patient is independent.
  • May shower at 2 weeks post-op but limit lifting and heavy exertion for 6 months.
  • Advise against future contact sports.
COMPLICATIONS
  • Neurologic injury
  • Infection (less than 1%)
  • Ileus
  • Atelectasis
  • Pneumothorax
  • Dural tear
  • Wrong level surgery
  • Urinary complications
  • Pseudarthorosis
  • Loss of lumbar lordosis
  • Crankshaft phenomenon
  • Superior mesenteric artery syndrome
  • Trunk decompensation
ANALYSIS OF RESULTS

The newer segmental fixation devices for the correction of spinal deformities from a posterior approach have a high rate of success with a low rate of complications.

OUTCOMES AND EVIDENCE
  • Hamill et al: Pedicle screws improved coronal and sagittal correction and had better restoration of segmental lordosis than hook configuration.
  • Barr et al: Pedicle screws provided greater lumbar curve correction, better maintenance of correction, and greater correction of the uninstrumented spine below double major curves when compared with hook configurations.
  • Suk et al: Hook fixation resulted in 55% correction compared to 72% with thoracic pedicle screws. Pedicle screws had a 3% malposition rate on radiographs.
  • Luhmann et al: Thoracic posterior-only pedicle screw constructs provided equal correction to hook constructs with anterior release.
  • Kim et al: Better curve correction without neurologic problems, improved pulmonary function, and shorter fusion length with posterior pedicle screw instrumentation compared to segmental hook instrumentation.
  • Liljenqvist et al: 25% of pedicle screws penetrated the pedicle cortex or anterior vertebral body cortex on CT scan, most clinically relevant in the thoracic spine.
Procedure: Laminar Hook Implantation

Post-Procedure: Instrumentation Sequence in Typical Lenke IA Curve

POST-PROCEDURE CARE
  • Restrict oral intake until bowel sounds are heard and monitor for an ileus.
  • Administer intravenous antibiotics for 48 hours after surgery.
  • Use "pulmonary toilet" and incentive spirometer to minimize atelectasis.
  • Use an anesthesia pump and/or oral pain medication to control postoperative pain.
  • Remove the Hemovac drain after 24 to 48 hours.
  • Mobilize the patient from the bed to a chair as soon as pain allows.
  • A brace is usually not necessary.
  • Discharge from hospital when oral intake is tolerated, temperature normalizes, and the patient is independent.
  • May shower at 2 weeks post-op but limit lifting and heavy exertion for 6 months.
  • Advise against future contact sports.
COMPLICATIONS
  • Neurologic injury
  • Infection (less than 1%)
  • Ileus
  • Atelectasis
  • Pneumothorax
  • Dural tear
  • Wrong level surgery
  • Urinary complications
  • Pseudarthorosis
  • Loss of lumbar lordosis
  • Crankshaft phenomenon
  • Superior mesenteric artery syndrome
  • Trunk decompensation
ANALYSIS OF RESULTS

The newer segmental fixation devices for the correction of spinal deformities from a posterior approach have a high rate of success with a low rate of complications.

OUTCOMES AND EVIDENCE
  • Hamill et al: Pedicle screws improved coronal and sagittal correction and had better restoration of segmental lordosis than hook configuration.
  • Barr et al: Pedicle screws provided greater lumbar curve correction, better maintenance of correction, and greater correction of the uninstrumented spine below double major curves when compared with hook configurations.
  • Suk et al: Hook fixation resulted in 55% correction compared to 72% with thoracic pedicle screws. Pedicle screws had a 3% malposition rate on radiographs.
  • Luhmann et al: Thoracic posterior-only pedicle screw constructs provided equal correction to hook constructs with anterior release.
  • Kim et al: Better curve correction without neurologic problems, improved pulmonary function, and shorter fusion length with posterior pedicle screw instrumentation compared to segmental hook instrumentation.
  • Liljenqvist et al: 25% of pedicle screws penetrated the pedicle cortex or anterior vertebral body cortex on CT scan, most clinically relevant in the thoracic spine.
Procedure: Instrumentation Sequence in Typical Lenke IA Curve

Post-Procedure: Thoracic Pedicle Screw Insertion Techniques

POST-PROCEDURE CARE
  • Restrict oral intake until bowel sounds are heard and monitor for an ileus.
  • Administer intravenous antibiotics for 48 hours after surgery.
  • Use "pulmonary toilet" and incentive spirometer to minimize atelectasis.
  • Use an anesthesia pump and/or oral pain medication to control postoperative pain.
  • Remove the Hemovac drain after 24 to 48 hours.
  • Mobilize the patient from the bed to a chair as soon as pain allows.
  • A brace is usually not necessary.
  • Discharge from hospital when oral intake is tolerated, temperature normalizes, and the patient is independent.
  • May shower at 2 weeks post-op but limit lifting and heavy exertion for 6 months.
  • Advise against future contact sports.
COMPLICATIONS
  • Neurologic injury
  • Infection (less than 1%)
  • Ileus
  • Atelectasis
  • Pneumothorax
  • Dural tear
  • Wrong level surgery
  • Urinary complications
  • Pseudarthorosis
  • Loss of lumbar lordosis
  • Crankshaft phenomenon
  • Superior mesenteric artery syndrome
  • Trunk decompensation
ANALYSIS OF RESULTS

The newer segmental fixation devices for the correction of spinal deformities from a posterior approach have a high rate of success with a low rate of complications.

OUTCOMES AND EVIDENCE
  • Hamill et al: Pedicle screws improved coronal and sagittal correction and had better restoration of segmental lordosis than hook configuration.
  • Barr et al: Pedicle screws provided greater lumbar curve correction, better maintenance of correction, and greater correction of the uninstrumented spine below double major curves when compared with hook configurations.
  • Suk et al: Hook fixation resulted in 55% correction compared to 72% with thoracic pedicle screws. Pedicle screws had a 3% malposition rate on radiographs.
  • Luhmann et al: Thoracic posterior-only pedicle screw constructs provided equal correction to hook constructs with anterior release.
  • Kim et al: Better curve correction without neurologic problems, improved pulmonary function, and shorter fusion length with posterior pedicle screw instrumentation compared to segmental hook instrumentation.
  • Liljenqvist et al: 25% of pedicle screws penetrated the pedicle cortex or anterior vertebral body cortex on CT scan, most clinically relevant in the thoracic spine.
Procedure: Thoracic Pedicle Screw Insertion Techniques

Post-Procedure: Thoracic Pedicle Screw Insertion Techniques

POST-PROCEDURE CARE
  • Restrict oral intake until bowel sounds are heard and monitor for an ileus.
  • Administer intravenous antibiotics for 48 hours after surgery.
  • Use "pulmonary toilet" and incentive spirometer to minimize atelectasis.
  • Use an anesthesia pump and/or oral pain medication to control postoperative pain.
  • Remove the Hemovac drain after 24 to 48 hours.
  • Mobilize the patient from the bed to a chair as soon as pain allows.
  • A brace is usually not necessary.
  • Discharge from hospital when oral intake is tolerated, temperature normalizes, and the patient is independent.
  • May shower at 2 weeks post-op but limit lifting and heavy exertion for 6 months.
  • Advise against future contact sports.
COMPLICATIONS
  • Neurologic injury
  • Infection (less than 1%)
  • Ileus
  • Atelectasis
  • Pneumothorax
  • Dural tear
  • Wrong level surgery
  • Urinary complications
  • Pseudarthorosis
  • Loss of lumbar lordosis
  • Crankshaft phenomenon
  • Superior mesenteric artery syndrome
  • Trunk decompensation
ANALYSIS OF RESULTS

The newer segmental fixation devices for the correction of spinal deformities from a posterior approach have a high rate of success with a low rate of complications.

OUTCOMES AND EVIDENCE
  • Hamill et al: Pedicle screws improved coronal and sagittal correction and had better restoration of segmental lordosis than hook configuration.
  • Barr et al: Pedicle screws provided greater lumbar curve correction, better maintenance of correction, and greater correction of the uninstrumented spine below double major curves when compared with hook configurations.
  • Suk et al: Hook fixation resulted in 55% correction compared to 72% with thoracic pedicle screws. Pedicle screws had a 3% malposition rate on radiographs.
  • Luhmann et al: Thoracic posterior-only pedicle screw constructs provided equal correction to hook constructs with anterior release.
  • Kim et al: Better curve correction without neurologic problems, improved pulmonary function, and shorter fusion length with posterior pedicle screw instrumentation compared to segmental hook instrumentation.
  • Liljenqvist et al: 25% of pedicle screws penetrated the pedicle cortex or anterior vertebral body cortex on CT scan, most clinically relevant in the thoracic spine.
Procedure: Thoracic Pedicle Screw Insertion Techniques

Post-Procedure: Iliac Fixation with Iliac Screws

POST-PROCEDURE CARE
  • Restrict oral intake until bowel sounds are heard and monitor for an ileus.
  • Administer intravenous antibiotics for 48 hours after surgery.
  • Use "pulmonary toilet" and incentive spirometer to minimize atelectasis.
  • Use an anesthesia pump and/or oral pain medication to control postoperative pain.
  • Remove the Hemovac drain after 24 to 48 hours.
  • Mobilize the patient from the bed to a chair as soon as pain allows.
  • A brace is usually not necessary.
  • Discharge from hospital when oral intake is tolerated, temperature normalizes, and the patient is independent.
  • May shower at 2 weeks post-op but limit lifting and heavy exertion for 6 months.
  • Advise against future contact sports.
COMPLICATIONS
  • Neurologic injury
  • Infection (less than 1%)
  • Ileus
  • Atelectasis
  • Pneumothorax
  • Dural tear
  • Wrong level surgery
  • Urinary complications
  • Pseudarthorosis
  • Loss of lumbar lordosis
  • Crankshaft phenomenon
  • Superior mesenteric artery syndrome
  • Trunk decompensation
ANALYSIS OF RESULTS

The newer segmental fixation devices for the correction of spinal deformities from a posterior approach have a high rate of success with a low rate of complications.

OUTCOMES AND EVIDENCE
  • Hamill et al: Pedicle screws improved coronal and sagittal correction and had better restoration of segmental lordosis than hook configuration.
  • Barr et al: Pedicle screws provided greater lumbar curve correction, better maintenance of correction, and greater correction of the uninstrumented spine below double major curves when compared with hook configurations.
  • Suk et al: Hook fixation resulted in 55% correction compared to 72% with thoracic pedicle screws. Pedicle screws had a 3% malposition rate on radiographs.
  • Luhmann et al: Thoracic posterior-only pedicle screw constructs provided equal correction to hook constructs with anterior release.
  • Kim et al: Better curve correction without neurologic problems, improved pulmonary function, and shorter fusion length with posterior pedicle screw instrumentation compared to segmental hook instrumentation.
  • Liljenqvist et al: 25% of pedicle screws penetrated the pedicle cortex or anterior vertebral body cortex on CT scan, most clinically relevant in the thoracic spine.
Procedure: Iliac Fixation with Iliac Screws

Post-Procedure: Posterior Multihook and Screw Segmental Instrumentation (Crandall)

POST-PROCEDURE CARE
  • Restrict oral intake until bowel sounds are heard and monitor for an ileus.
  • Administer intravenous antibiotics for 48 hours after surgery.
  • Use "pulmonary toilet" and incentive spirometer to minimize atelectasis.
  • Use an anesthesia pump and/or oral pain medication to control postoperative pain.
  • Remove the Hemovac drain after 24 to 48 hours.
  • Mobilize the patient from the bed to a chair as soon as pain allows.
  • A brace is usually not necessary.
  • Discharge from hospital when oral intake is tolerated, temperature normalizes, and the patient is independent.
  • May shower at 2 weeks post-op but limit lifting and heavy exertion for 6 months.
  • Advise against future contact sports.
COMPLICATIONS
  • Neurologic injury
  • Infection (less than 1%)
  • Ileus
  • Atelectasis
  • Pneumothorax
  • Dural tear
  • Wrong level surgery
  • Urinary complications
  • Pseudarthorosis
  • Loss of lumbar lordosis
  • Crankshaft phenomenon
  • Superior mesenteric artery syndrome
  • Trunk decompensation
ANALYSIS OF RESULTS

The newer segmental fixation devices for the correction of spinal deformities from a posterior approach have a high rate of success with a low rate of complications.

OUTCOMES AND EVIDENCE
  • Hamill et al: Pedicle screws improved coronal and sagittal correction and had better restoration of segmental lordosis than hook configuration.
  • Barr et al: Pedicle screws provided greater lumbar curve correction, better maintenance of correction, and greater correction of the uninstrumented spine below double major curves when compared with hook configurations.
  • Suk et al: Hook fixation resulted in 55% correction compared to 72% with thoracic pedicle screws. Pedicle screws had a 3% malposition rate on radiographs.
  • Luhmann et al: Thoracic posterior-only pedicle screw constructs provided equal correction to hook constructs with anterior release.
  • Kim et al: Better curve correction without neurologic problems, improved pulmonary function, and shorter fusion length with posterior pedicle screw instrumentation compared to segmental hook instrumentation.
  • Liljenqvist et al: 25% of pedicle screws penetrated the pedicle cortex or anterior vertebral body cortex on CT scan, most clinically relevant in the thoracic spine.
Procedure: Posterior Multihook and Screw Segmental Instrumentation (Crandall)

Post-Procedure: Posterior Column Shortening Procedure for Scheuermann's Kyphosis (Ponte)

POST-PROCEDURE CARE
  • Restrict oral intake until bowel sounds are heard and monitor for an ileus.
  • Administer intravenous antibiotics for 48 hours after surgery.
  • Use "pulmonary toilet" and incentive spirometer to minimize atelectasis.
  • Use an anesthesia pump and/or oral pain medication to control postoperative pain.
  • Remove the Hemovac drain after 24 to 48 hours.
  • Mobilize the patient from the bed to a chair as soon as pain allows.
  • A brace is usually not necessary.
  • Discharge from hospital when oral intake is tolerated, temperature normalizes, and the patient is independent.
  • May shower at 2 weeks post-op but limit lifting and heavy exertion for 6 months.
  • Advise against future contact sports.
COMPLICATIONS
  • Neurologic injury
  • Infection (less than 1%)
  • Ileus
  • Atelectasis
  • Pneumothorax
  • Dural tear
  • Wrong level surgery
  • Urinary complications
  • Pseudarthorosis
  • Loss of lumbar lordosis
  • Crankshaft phenomenon
  • Superior mesenteric artery syndrome
  • Trunk decompensation
ANALYSIS OF RESULTS

The newer segmental fixation devices for the correction of spinal deformities from a posterior approach have a high rate of success with a low rate of complications.

OUTCOMES AND EVIDENCE
  • Hamill et al: Pedicle screws improved coronal and sagittal correction and had better restoration of segmental lordosis than hook configuration.
  • Barr et al: Pedicle screws provided greater lumbar curve correction, better maintenance of correction, and greater correction of the uninstrumented spine below double major curves when compared with hook configurations.
  • Suk et al: Hook fixation resulted in 55% correction compared to 72% with thoracic pedicle screws. Pedicle screws had a 3% malposition rate on radiographs.
  • Luhmann et al: Thoracic posterior-only pedicle screw constructs provided equal correction to hook constructs with anterior release.
  • Kim et al: Better curve correction without neurologic problems, improved pulmonary function, and shorter fusion length with posterior pedicle screw instrumentation compared to segmental hook instrumentation.
  • Liljenqvist et al: 25% of pedicle screws penetrated the pedicle cortex or anterior vertebral body cortex on CT scan, most clinically relevant in the thoracic spine.
Procedure: Posterior Column Shortening Procedure for Scheuermann's Kyphosis (Ponte)
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