CHAPTER
97
Vertebral Column Resection for
Complex Spinal Deformity: Anterior
and Posterior Approach
INTRODUCTION AND BACKGROUND
The management of patients with complex spinal deformity
is a difficult challenge. Patients with complex deformity of the
spine encompass those with malalignment of the spine in the
coronal, sagittal, and axial spine. Complex deformities are spi-
nal disorders that are fixed, or rigid, and that cannot be effec-
tively corrected with traditional techniques of angular correction.
Shortening of the spinal column, with translation of the spine
and correction of coronal, sagittal, and axial deformity, is the
key component of surgical care for complex deformity. The
goals of surgical care are (1) restoration of three dimensional
balance, (2) rigid internal fixation with minimal external sup-
port or immobilization, (3) solid arthrodesis, and (4) improved
quality of life as measured by function, pain, self-esteem, and
general health status. The purpose of this chapter is to review
the techniques for correction of complex spinal deformity and
to detail the historical position, the present role, and the tech-
nique of the combined anterior and posterior vertebral column
resection.
Conventional surgical techniques for the management of
spinal deformity include posterior segmental instrumenta-
tion, anterior correction, and combined anterior and poste-
rior surgery. These conventional approaches have significant
limitations in the management of rigid spinal decompensa-
tion and complex deformity. Specifically, by maintaining
length of the spinal column, correction may be limited, and
there is a significant risk of neurologic injury associated with
excessive distraction of the concavity.11,28 Neural deficit, pseu-
darthrosis, persistent spinal imbalance, and flatback defor-
mity are well-documented complications associated with con-
ventional techniques in the management of complex spinal
deformity.4,6,9 Spinal shortening procedures for the manage-
ment of severe fixed decompensation address the recognized
limitations of conventional approaches. This chapter will
review the history and evolution of spinal shortening proce-
dures for treatment of severe fixed spinal decompensation,
and detail the present role of a combined anterior and poste-
rior approach for surgical management of complex spinal
deformity.
LWBK836_Ch97_p1015-1020.indd 1015
Sigurd Berven
David S. Bradford
SPINAL SHORTENING PROCEDURES
Leatherman observed that in order to correct a rigid spine
without incurring the danger of traction paraplegia, the spine
must be shortened as well as straightened.18 Spinal shortening
with vertebrectomy was first developed for the management of
deformity secondary to congenital hemivertebra. In a classic
description on the etiology of scoliosis as well as a technique for
management of severe deformity, MacLennan first described
the technique of a vertebral body resection through a posterior
approach. He described an excavation of the vertebral body at
the apex of the deformity, with partial vertebrectomies above
and below the level, followed by plaster casting. However, he
reports surprisingly little correction, due to the rigidity of the
retained posterior elements.20 Royle described a vertebrectomy
for excision of a hemivertebrae in 1928, although he offered no
results or follow-up on clinical outcome.24 Between 1924 and
1933, Von Lackum and Smith performed a combined anterior
vertebrectomy and posterior fusion in the management of fixed
lateral deformity in five patients with congenital hemivertebrae
and five patients with ordinary scoliosis. They concluded that
removal of the posterior arch and vertebral body is the only
means of correcting lateral curvature due to congenital
hemivertebrae or severe lateral curvature in the lumbar spine
due to ordinary scoliosis.29 Von Lackum and Smith also con-
cluded that removal of vertebral bodies from the thoracic spine
is impracticable because of the danger from hemorrhage and
shock. Compere achieved marked correction of deformity with
excision of the convex hemivertebra in two cases in 1932.5 In
1951, Wiles reported complications of progressive kyphosis in
two cases of lumbar hemivertebra excision, and subsequent dis-
cussion revealed that follow-up of the earlier experiences of
Compere and Von Lackum similarly demonstrated progressive
kyphosis and deformity.30
In 1965, Hodgson demonstrated that fixed spinal curves
could be effectively treated with spinal osteotomy and anterior
fusion.11 As a pioneer of anterior approaches to the spine for
management of deformity caused by Potts disease of the spine,
Hodgson contributed significant insight into the anterior man-
agement of fixed spinal deformity due to other etiologies.12 He
1015
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 1016 Section VIII Adult Spinal Deformity
identified two main methods by which coronal correction could
be obtained in the management of fixed deformity: (1) osteotomy
on the convex side with wedging the spine open or (2) osteot-
omy on the concave side with a closing wedge. He reported suc-
cess in two cases using the opening wedge method, achieving
up to 25 correction of coronal deformity. However, the effec-
tive restoration of spinal balance using an opening wedge on
the concave side of the curve is clearly limited by the risk of
spinal cord embarrassment, by lengthening of the spinal col-
umn, and by the risk of exacerbation of shoulder imbalance in
the case in which the lower shoulder is on the side of the con-
vexity. Vascular compromise associated with the opening
wedge technique as described by Hodgson has also been
reported. Domisse and Enslin reported four cases of paraplegia
in 68 operations for scoliosis using a circumferential spinal
osteotomy as described by Hodgson.8 Three out of these four
cases occurred between T5 and T9, a region which they identi-
fied through anatomic study to be a critical vascular zone of the
spinal cord.7 The technique of hemivertebra excision for the
management of fixed deformity due to congenital anomaly has
been described more recently by several authors, with reliable
deformity correction, although largely limited to the lumbar
region.3,13,16
A two-stage corrective surgery for correction of congenital
deformities using a closing wedge osteotomy rather than an
opening wedge was described by Leatherman in 1969.17
Shortening as well as straightening the spine permits correc-
tion of rigid deformity with preservation of neurologic func-
tion. Stage 1 involves excision of a single apical vertebra, limit-
ing resection to avoid jeopardizing circulation to the spinal
cord. Stage 2 involves posterior fusion of the entire structural
curve, with correction using compression and distraction
instrumentation. In 1979, Leatherman reported results of two-
stage corrective surgery for congenital deformities of the spine,
with an average of 47% correction and no permanent neuro-
logic complications.16
The application of the principle of spinal shortening to cre-
ate a lateral transposition of the spine was introduced by
Eduardo Luque in 1983.20 Luque described a technique of par-
tial anterior vertebrectomies through anterior fenestrations
with preservation of the segmental vessels, followed by green-
stick fracturing of the vertebral cortex. A second stage 2 weeks
later involved posterior removal of pedicles and correction with
shortening. Luque reported results on eight patients, partially
removing between three and eight vertebrae on the convexity,
with convex rib resections in all cases. He reported an average
curve correction of 86%, with no neurologic compromise.
Bradford first described a modification of Luques technique
for managing severe rigid deformity of the spine, which he
termed, vertebral column resection.2 While Luques tech-
nique involved only decancellation through fenestrations,
Bradfords original technique involved segmental vessel liga-
tion, decancellation to the level of the dura over several
segments, anterior releases and fusion proximal and distal to
the resection area, and reconstruction with an osteoperiosteal
flap followed by posterior resection and concave rib osteoto-
mies and convex thoracoplasty. The vertebral column resection
permits correction of deformity in the coronal, sagittal, and
axial planes, while minimizing the risk of neurologic injury and
decompensation of the overall balance of the spine. The com-
bined anterior and posterior approach to the spine described
by Bradford is the most effective technique for a thorough
LWBK836_Ch97_p1015-1020.indd 1016
mobilization of the trunk relative to the pelvis and has been
considered less risky to the neural elements than a blind decan-
cellation from anterior or posterior approaches.
Posterior approaches to the correction of complex spinal
deformity include the transpedicular decancellation or wedge
research procedures, and a posterior-based vertebral column
resection. Transpedicular decancellation of vertebral bodies
was first described as a technique for the diagnosis for vertebral
lesions by Michele and Kruger in 1949.22 Thomasen described
the transpedicular wedge resection osteotomy for the correc-
tion of sagittal deformity in ankylosing spondylitis, offering a
spinal shortening procedure to avoid the described risks of
neurologic, vascular, and visceral injury associated with the
Smith-Peterson closing wedge osteotomy.27 In 1976, Lehmer
et al. published a series of 41 cases in 38 consecutive patients
treated with transvertebral osteotomy for the management of
kyphosis due to trauma or laminectomy. The authors report an
average correction of 35 but new neural deficits in 19.5% of
patients.19 Correction of more complex deformity in more than
one plane through shortening of the spinal column from a
transpedicular route was popularized as the eggshell proce-
dure by Chewning and Heinig.10 However, in more severe
rigid, decompensated deformity, this technique may prove
insufficient due to a limited ability to translate the spine, and a
primary sagittal plane of correction. A posterior vertebral col-
umn resection involves the complete resection of one or more
vertebra from a single posterior approach. The application of
posterior-only vertebral column resection to patients with com-
plex spinal deformity was introduced by Professor Suk in a
series of 70 patients. The authors reported impressive correc-
tion of deformity but a high rate of neural injury including
complete spinal cord injury.26 The posterior-only approach to
vertebral column resection is especially useful in the spine with
a sharp apical kyphosis, or in the patient with an apical defor-
mity that is limited to one or two segments. The combined
anterior and posterior approach to vertebral column resection
permits resection of more vertebral segments for more exten-
sive deformities, is more effective for patients with thoracic or
thoracolumbar hypokyphosis, and may be a safer alternative
regarding risk to the neural elements.
VERTEBRAL COLUMN RESECTION
INDICATIONS FOR VERTEBRAL
COLUMN RESECTION
Flexible compensated, flexible decompensated, and fixed com-
pensated deformity can all be managed surgically with conven-
tional techniques including angular correction and balanced
compression and distraction. Vertebral column resection is
reserved for the fixed decompensated spinal deformity. The
surgical planning and decision making in choosing between a
conventional anterior and posterior reconstruction and a verte-
bral column resection and shortening requires consideration
of the following factors:
Magnitude of Coronal Imbalance
An attempt to correct large deformities without shortening of
the spine is a risk of neurologic compromise. Coronal plane
correction increases the vertical displacement of the spinal
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 Chapter 97 Vertebral Column Resection for Complex Spinal Deformity: Anterior and Posterior Approach
cord from the pelvis, as well as the horizontal position of the
spinal cord relative to peripheral myotomes. Spinal shortening
minimizes tension on the spinal cord and peripheral nerves.
We prefer to shorten the spine with a vertebral resection in
curves resulting in more than 6 cm of coronal imbalance.
Fixed Translatory Deformity
Translation of the spine refers to a horizontal displacement of
the spine relative to the pelvis. Correction of translational
deformity cannot be accomplished without spinal column
shortening because of the coupled motions of the spine in
three dimensions, and the generation of rotatory displacement
with attempted apical translation without shortening.
Presence of a Fixed Upper Thoracic Curve or an
Oblique Lumbosacral Takeoff
The fixed upper thoracic or lower lumbar curves are especially
difficult as correction of deformity must be precise because
there are few cephalad or caudal segments respectively to per-
mit compensation for residual deformity, shoulder imbalance,
or pelvic obliquity. Spinal shortening permits reliable correc-
tion of deformity in three planes, without reliance on signifi-
cant adjacent segment compensation.
Asymmetric Lengths Between the Concave and Convex
Sides of the Vertebral Column
Conventional correction methods rely on a compensatory curve
that, with appropriate manipulation through osteotomy or seg-
mental compression and distraction, can afford overall balance
to the spine. In the patient with a long fixed curve pattern with
the convexity of the curve ipsilateral to the direction of displace-
ment in the coronal plane, attempts to reduce the magnitude of
the curve while maintaining spinal length with conventional
techniques will exacerbate coronal displacement.
Direction of Shoulder Asymmetry
Shoulder asymmetry can be exacerbated by conventional tech-
niques of restoration of coronal balance. A conventional ante-
rior osteotomy with posterior fusion is appropriate for patients
in whom correction of the coronal deformity contributes to bal-
ance of the upper curve and shoulders. This patient presents
with fixed decompensation in which the shoulder contralateral
to the coronal displacement is elevated, and has a type 1 coro-
nal plane deformity (Fig. 97.1A). In patients with ipsilateral
shoulder elevation and coronal displacement, the shoulders
are at risk for progressive decompensation unless the spinal
column is shortened, as a closing wedge osteotomy to correct
coronal plane deformity would clearly exacerbate shoulder
asymmetry. Patients with a deformity that is not correctable
without translation of the trunk have a type 2 coronal plane
deformity (Fig 97.1B).
Vertebral column resection is therefore indicated only for a
subgroup of patients with severe fixed coronal decompensa-
tion. It is valuable for the surgeon to understand the limitations
of conventional techniques for this group, and the indications
for a more radical resection procedure when a standard angu-
lar correction technique is less likely to be successful.
LWBK836_Ch97_p1015-1020.indd 1017
1017
A B
Figure 97.1. (A) Type 1 coronal plane deformity. (B) Type 2 coronal
plane deformity.
PREOPERATIVE EVALUATION
A clear understanding of patient expectations from surgical
intervention serves the objective of providing care that is
responsive to the patient rather than reactive to radiographic
and ancillary findings. A careful history of pain pattern, includ-
ing onset, magnitude, frequency, and exacerbations, is impor-
tant. Evidence of deformity progression may be apparent,
either from prior radiographs or from a history of progressive
height loss or curve pattern change. Preoperative cardiac and
pulmonary assessment is of special importance in the adult
patient, especially in a surgical era when age is not a contrain-
dication to major deformity correction. Preoperative pulmo-
nary function testing is useful in patients with a history of
frequent pneumonias, associated neuropathic (cerebral palsy,
poliomyelitis) or myopathic (muscular dystrophy, primary myo-
pathies) weakness, or subjective dyspnea. Irreversible preopera-
tive vital capacity compromise is a predictor of postoperative
respiratory complications.1,23 Other areas of physical health to
assess include bone quality, nutritional status, obesity, and
tobacco use. Each of these areas may be optimized before con-
sidering elective surgical correction. In addition to physical
health, the surgeon may consider social, financial, and psycho-
logical well-being of the patient, as vertebral resection surgery
and subsequent recovery will surely impact all of these areas.
Radiographs are a useful part of the preoperative assess-
ment. Routine standing preoperative PA and lateral roentgeno-
grams on a 14 36-inch cassette are most helpful. Supine
bending or traction films are informative in the assessment of
curve flexibility, and in choosing resection and fusion levels.
Coronal decompensation is measured lateral deviation between
the central sacral line and the center of C7. A rigid deformity
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 1018 Section VIII Adult Spinal Deformity
will have minimal correction with bending or traction. A large
rigid idiopathic deformity may be difficult to differentiate from
a congenital scoliosis. Therefore, preoperative magnetic reso-
nance imaging (MRI) or myelography is useful in ruling out
intraspinal anomalies that are frequently seen in the congenital
cases. A detailed preoperative neurological assessment is also
useful in screening for intraspinal anomalies and in identifying
possible radicular or central pathology.25 Preoperative MRI or
computed tomography (CT) with myelography is also helpful
in assessment of spinal stenosis, disc degeneration, and assess-
ment of radicular pain patterns. Discography has been reported
as a useful technique for evaluation of fusion levels in adult
scoliosis surgery,15 although we do not routinely use the test
and prefer to fuse to a stable, neutral level with no plain film
evidence of instability or adjacent pathology.
SURGICAL PLANNING
Successful surgery requires cooperation of multiple physicians
detailed preoperative planning and organization of resources.
An experienced anesthetic team skilled in the management of
large fluid shifts and hypotensive anesthesia is important for
patient safety. Blood management may include preoperative
autogenous donation, with retention of platelets and clotting
factors, and intraoperative cell saver. Neuromonitoring is valu-
able during vertebral resection. We prefer cortical motor
evoked potentials with somatosensory evoked potential moni-
toring, although multiple wake-up tests may also be performed
during the procedure. If stages are to be delayed, we recom-
mend an interval of 4 to 7 days. Hyperalimentation between
stages minimizes nutritional deficiency and associated compli-
cations of infection, sepsis, and pneumonia.14 Hyperalimenta-
tion may be administered either intravenously or through a
nasojejunal feeding tube.
Surgical Technique
The vertebral resection procedure is performed in two stages.
Anterior Stage
An anterior approach to the convex side of the curve to be
resected is performed through a standard thoracotomy or tho-
racoabdominal approach. The rib corresponding to the upper-
most vertebra to be resected is excised during the approach,
and morselized for supplementation of autogenous bone graft.
The number of vertebra to be resected is determined preop-
eratively. For sharp short curves, a single vertebra may be ade-
quate, while for a long and sweeping deformity, resection of
two to three vertebrae may be required for effective curve cor-
rection without stretching the spinal cord. The segmental ves-
sels of each vertebra to be excised are ligated and divided. An
extraperiosteal circumferential exposure of the spine over the
segments to be resected is the next step, and this can be
achieved with blunt dissection, following the avascular interval
over the intervertebral discs in establishing a safe plane.
After the spine is circumferentially exposed, complete dis-
cectomies are performed to the level of the posterior longitudi-
nal ligament. Osteophytes and ankylosis on the concave side
are resected to gain mobility of the spine, and the extrape-
riosteal circumferential exposure of the spine permits safe and
effective excision of concave restraints to mobility. Disc spaces
LWBK836_Ch97_p1015-1020.indd 1018
are packed with gelfoam soaked in thrombin solution, or
Oxycel (Becton Dickinson and Company, Franklin Lakes, NJ)
to prevent extraneous blood loss.
An osteoperiosteal flap composed of outer cortex and
periosteum of each vertebra to be resected is created with a
sharp, curved osteotome. The inner cancellous bone of each
vertebra is removed with rongeurs or a high-speed burr, fol-
lowed by curettes posteriorly to the posterior cortical shell. The
convex pedicle is easily removed from the anterior approach,
although the concave pedicle can only be partially resected and
will require further excision from the posterior approach. The
posterior cortical shell is removed lastly, using small curettes to
separate the thin bony shell from the posterior longitudinal
ligament and epidural space. Epidural bleeding may be signifi-
cant at this stage, and hemostasis is secured with gelfoam soaked
in thrombin solution or Oxycel applied directly to the dura.
Thrombin soaked gelfoam may be applied to protect the dura,
followed by overlay of cancellous bone resected and the morsel-
ized rib. The osteoperiosteal flap is then reapproximated using
0-vicryl to retain the graft in position.
Meticulous hemostasis is necessary before continuing with
the next stage.
Posterior Stage
If blood loss is well-managed (1000 cc), and the time for the
anterior procedure is less than 4 to 5 hours, then we may per-
form the posterior procedure on the same day, under the same
anesthetic. It is our experience that these conditions are
unusual, and more commonly, the second stage is performed
on a second day delayed 4 to 7 days. After surgery, the patient
is placed on total parenteral or enteric hyperalimentation to
minimize nutritional deficiency and associated risk of infec-
tion, sepsis, and pneumonia. Activity between stages is deter-
mined by residual posterior stability. If the spine is rigid due to
prior posterior fusion that is stable, then the patient may get
out of bed to a chair without a brace, or ambulate with a thora-
columbar orthosis. Should the anterior resection render the
spine functionally unstable, bedrest with or without halo trac-
tion is maintained.
The posterior approach is performed as a routine subpe-
riosteal exposure of the spine to the tips of the transverse pro-
cesses. Mobilization of the deformity is next addressed. Rib dis-
articulation from the transverse processes may be necessary to
obtain mobility over the concavity of the curve. On the convex-
ity, thoracoplasty is usually necessary to improve correction and
to address residual rib prominence. Osteotomies are performed
across fused facets along the deformity to further gain mobility
at each segment. Implants including pedicle screws and hooks
or sublaminar wires are next placed, prior to completion of
removal of the posterior elements of the resected vertebrae.
The posterior elements including facets, lamina, and residual
concave-sided pedicle are then removed.
Instrumentation of the spine is performed beginning on the
convex side, using cantilever mechanics to correct coronal, sag-
ittal, and axial deformity simultaneously. It is only by gaining
adequate mobilization of the spine with complete resection
and shortening that effective three-dimensional correction can
be achieved. Dural redundance is expected, and dural pulsa-
tions are evaluated to indicate excessive distraction or compres-
sion. Multiple wake-up tests are useful during the corrective
procedure. Intraoperative somatosensory and motor evoked
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 Chapter 97 Vertebral Column Resection for Complex Spinal Deformity: Anterior and Posterior Approach 1019

potentials may supplement neurologic monitoring. Correction
is gradual and done carefully to avoid excessive tension or com-
pression on neural elements.
The goal of instrumentation is to obtain and maintain bal-
ance in the coronal and sagittal planes, placing C7 over the poste-
rior sacral prominence in the sagittal plane, and over the central
sacral line in the coronal plane. Total correction of the defor-
mity is possible though not necessary to achieve balance.
Postoperative Care
Postoperatively, patients may transfer from bed to chair on day
1 or 2, without an orthosis. A thoracolumbar sacral orthosis is fit
on postoperative day 3, and the patient may ambulate with this
orthosis. Serial radiographs are taken in the recovery room, on
discharge, at 6 weeks, 3 months, 6 months, and thereafter yearly.
Union and biologic stability of the vertebral column is expected
at 6 months, at which point brace use may be discontinued.
REPRESENTATIVE CASE
Figures 97.2A to F show a representative case. The patient is a
15-year-old girl with a type 2 coronal plane deformity. Conven-
tional angular osteotomies would exacerbate both shoulder
asymmetry and trunk shift. A four-level anterior vertebral

A B C

D E F

Figure 97.2. Case 1: (A, B) Preoperative clinical photographs of a 15-year-old girl with congenital scoliosis.
(C) Preoperative PA radiograph. (D, E). Postoperative clinical photographs. (F) Postoperative PA radiograph.

LWBK836_Ch97_p1015-1020.indd 1019 8/26/11 2:51:31 PM

 1020 Section VIII Adult Spinal Deformity
column resection followed by posterior segmental instrumenta-
tion led to a well-balanced correction of deformity with trunk
shift corrected and shoulder asymmetry improved.
SUMMARY
The vertebral resection procedure is a demanding technique
with limited indications. Vertebral resection is indicated when
conventional posterior, anterior, and combined approaches are
of limited efficacy in correcting severe fixed decompensation
of the spine, or when correction with conventional techniques
would risk neurologic compromise. Specific indications include
the following:
(1) Coronal imbalance of greater than 6 cm.
(2) Fixed truncal translation.
(3) Fixed upper thoracic curves, or lumbosacral obliquity.
(4) Asymmetric length of the convex and concave curves.
(5) Shoulder asymmetry that would be exacerbated by conven-
tional techniques.
The vertebral resection procedure is a demanding tech-
nique and is significantly more involved than a vertebrectomy
or conventional combined technique. Important distinguish-
ing characteristics of the procedure include an extensive resec-
tion (more than one spinal segment), rib releases or osteoto-
mies on the convex and concave sides of the resection segments,
total removal of the posterior arch at the level of the resection,
posterior osteotomies and facetectomies above and below the
resection, as well as anterior osteotomies and discectomies
above and below the resected levels. A posterior-only vertebral
column resection may be effective for spinal deformity that is
focal and in which the apex of coronal and sagittal deformity
are matched. The combined anterior and posterior approach
may be more effective in treating the patient with a deformity
that extends across multiple segments, deformity that involves
multiple apices, including different apices in the coronal and
sagittal plane, and in the spine with hypokyphosis or lordosis
across the thoracic spine. Spinal shortening permits compensa-
tion in multiple planes simultaneously, while avoiding distrac-
tion of neural elements. In the patient with severe fixed coro-
nal decompensation, the vertebral resection procedure is an
effective management technique for restoration of overall spi-
nal balance.
LWBK836_Ch97_p1015-1020.indd 1020
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