Fadi Nasr
CHAPTER
98
Minimally Invasive Deformity
Surgery: Future Directions
Minimally invasive techniques in spine surgery have been evolv-
ing for the past several years.7,9 Their advent has brought with
it many benefits to the patient undergoing surgery for degen-
erative spine disease. Among these benefits are less blood loss,
less postoperative discomfort, faster recovery time, and, argu-
ably the most important benefit, decreased injury to the
paraspinal soft tissue envelope.2,3
This final benefit is of utmost importance when considering
that the overall biomechanical strength of the spine rests on
the soft tissue envelope remaining intact.4,5 This soft tissue
envelope includes the paraspinous musculature, the ligamen-
tous structures, and the articular facet joints and capsules.
Injury to the paraspinal envelope can lead to premature degen-
eration at adjacent levels leading to a shortened time to revi-
sion surgery after primary spine surgery.
In the patient with spinal deformity, the current techniques
of open surgical exposure completely denude the spine of its
soft tissue support. The dorsal tension band is disrupted with
injury to both ligamentous structures as well as injury to paraspi-
nal musculature. In addition, there is always concern over injury
to the facet structures adjacent to the fusion. All of this injury
may lead to premature proximal or distal junctional failure.
We are currently in the process of transition in deformity
surgery. Minimally invasive techniques are now beginning to be
utilized as powerful tools in the correction of deformity to the
benefit of the patient. This chapter will explore the current
minimally invasive technologies available to the deformity sur-
geon. We will describe the techniques as well as their applica-
tion in correcting deformity. We will also include several case
studies that illustrate their use.
INDICATIONS
Indications for utilizing minimal access techniques in spinal
deformity are currently being developed. Many factors go into
deciding who will be an appropriate candidate. All deformity
patients should have standing 36-inch scoliosis X-rays as well as
supine and side bending X-rays to evaluate their curves. Sagittal
and coronal balance is taken into consideration. Patients are
evaluated for curve flexibility, possibility of short segment cor-
rection of their deformity, and possibility of preservation of the
caudal motion segments.
LWBK836_Ch98_p1021-1030.indd 1021
Tyler Koski
John Liu
Stephen Ondra
Richard Fessler
Several criteria are being used to select patients for minimal
access approaches. The relative flexibility of the curve is deter-
mined using upright and recumbent films as well as push prone
films. Those curves that can be corrected using Smith-Petersen
osteotomies and positioning that do not require extensive
cantilever techniques for correction are candidate curves.
Short segment coronal deformity is also ideal for lateral inter-
body correction through minimally invasive retroperitoneal
approaches. Also, curves requiring short segment fixation to L5
or higher are candidate curves.
At this time, there are several relative contraindications to
minimal access deformity correction. Highly rigid, large angle
curves that require long segment fixation from the upper tho-
racic spine across the thoracolumbar junction or lumbosacral
junction pose significant challenges to the current state of tech-
nology. Techniques for dorsal approach minimal access pedicle
subtraction osteotomies and vertebral column resections have
not been fully developed, and the need for these osteotomies
may indeed be a relative contraindication to a minimal access
surgery. Rodding techniques are a major limitation for large
curves as the current percutaneous rod passing techniques can-
not account for the significant changes between thoracic
kyphosis and lumbar lordosis. Also, the degree of ankylosis
across anterior segments or posteriorly can pose a significant
challenge to adequate curve correction. The degree of sacral
obliquity can significantly complicate the correction of a lum-
bar degenerative curve and must be taken into account when
planning a minimally invasive correction. As our techniques
and technology evolve, we anticipate that these limitations will
be overcome.
EXPOSURE
When considering minimally invasive techniques, exposure of
the entire spinal column is not necessary. Only the key ele-
ments required for deformity correction are exposed. This
means that a keyhole approach to the spine must be under-
taken in order to expose the facet, pedicle entry zones, osteot-
omy sites, and arthrodesis sites. This approach minimizes soft
tissue envelope trauma while allowing correction to take place.
Keyhole exposure is undertaken posteriorly to enable osteoto-
mies, placement of instrumentation, and posterior arthrodesis.
1021
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 1022 Section VIII Adult Spinal Deformity
Anterior keyhole exposure is performed for interbody arthrod-
esis, indirect decompression, and correction of sagittal and
coronal deformity.
ANTERIOR EXPOSURE RELEASE
AND ARTHRODESIS
Anterior access to the lumbar spine in the past meant a large
lateral incision for a retroperitoneal exposure with significant
morbidity.1,8 This morbidity is associated with a large muscle
incision that can significantly prolong hospital stays. With new
techniques, a retroperitoneal exposure of the lateral disc space
can be accomplished with a minimal incision that is muscle
sparing and has minimal morbidity. Also, this technique can be
easily performed without the need for an access surgeon and
the operative time involved in exposure and closure is signifi-
cantly less.6
This so called direct lateral approach to the disc space can
be a very powerful tool in deformity correction. In patients with
a significant coronal imbalance, it allows for powerful correc-
tion by placing a large interbody graft that crosses the disc
space and is parallel to the end plates. This action forces the
end plates into a parallel configuration in the coronal plane
that corrects coronal plane deformity. When the graft is placed
anteriorly in the disc space, it distracts the end plates and
induces a lordosis that can help correct sagittal plane defor-
mity. If foraminal compression is present, the distraction of the
disc space provides for an indirect decompression of the nerve
roots. In addition, if there is ankylosis at the lateral edge of the
disc space, the procedure is effective at providing an anterior
release.
Given favorable anatomy, the direct lateral exposure can be
used to expose the lower thoracic disc spaces down to the L4/5
interspace. Sometimes the L4/5 interspace is obscured by the
iliac crest and cannot be accessed laterally. The L5/S1 inter-
space is almost always obscured by the iliac crest and can usu-
ally not be accessed laterally. Interspaces obscured by the iliac
crest must be accessed either through an anterior retroperito-
neal exposure or posteriorly via a posterior interbody or trans-
foraminal interbody approach.
The procedure is performed as follows.6 The patient is
placed in a lateral decubitus position. Usually the left side is
used as the approach side to avoid injury to the venous struc-
tures; however, the right side is used if it facilitates access to the
disc space given the deformity. The lateral position allows for
the abdominal contents to fall away facilitating retroperitoneal
access while reducing the risk of injury to the peritoneal con-
tents. The patient is placed on the bed so that the bed can be
flexed at the level of the pelvis. This allows opening of the space
between the iliac wing and the lowest rib and moves the iliac
crest down to facilitate access to the spine and to the lowest disc
space. The L4/5 disc space can almost always be accessed with
some help from positioning. After the patient is positioned, the
fluoroscope is brought into the field and placed at 0 so that
the X-ray is perfectly parallel to the floor in an anteroposterior
projection with respect to the patient. The spinous processes of
the vertebral segments immediately adjacent to the disc space
to be operated upon are positioned perfectly in the midline
between the pedicle silhouette by rotating the bed around its
long axis (Fig. 98.1). In this position, all work in the disc space
can be performed perpendicular to the floor, which should
LWBK836_Ch98_p1021-1030.indd 1022
Figure 98.1. Anteroposterior fluoro X-ray showing the spinous
process exactly midline between the pedicle silhouette at the levels
above and below the disc of interest.
make all actions perfectly transverse across the disc space lead-
ing to good graft placement and minimizing the risk of injury
to either the nerve roots posteriorly or the great vessels anteri-
orly. After this, the fluoro is rotated to a lateral projection to
localize the interspace and plan the incision. A transverse inci-
sion approximately 2 to 3 cm in length is then planned overly-
ing the anterior third of the disc space. The patient is then
prepped and draped. The surgeon should stand at the patients
abdomen so that all dissection is carried out toward the retro-
peritoneal space. The incision is opened down to the external
oblique facia. Each muscle layer is then split with blunt dissec-
tion until the transversalis facia is encountered. This is then
penetrated bluntly being careful not to enter the peritoneum.
The retroperitoneal fat is then immediately visible. This is
bluntly dissected with finger dissection being careful to sweep
the peritoneal contents anteriorly all the way down until the
psoas muscle is encountered. At this point, a neuromonitoring
probe can be inserted and stimulation is undertaken to ensure
that no traversing nerve roots are in the local area of dissection.
Once the area is deemed clear, a blunt k-wire can be inserted
into the disc space being careful not to pass the k-wire all the
way through the disc space and into the abdominal cavity on
the other side (Fig. 98.2). The psoas is then sequentially dilated
and a tubular retractor is placed. Dilation of the psoas muscle is
frequently associated with postoperative transient weakness of
hip flexion and some thigh discomfort due to local inflamma-
tion and irritation of the genitofemoral nerve. This is a self-
limited phenomenon and we have had no cases of persistent
problems.
Positioning of the retractor is checked with fluoroscopy. The
ideal position to start the discectomy is in the anterior one third
of the disc space, preferably just as the annulus begins to slope
medially (Fig. 98.3). This position allows for anterior place-
ment of an interbody graft that provides significant lordosing
action.
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 Chapter 98 Minimally Invasive Deformity Surgery: Future Directions
Figure 98.2. Diagram of a blunt k-wire in the disc space.
The lateral annulus of the disc space is then cleared of any
remaining psoas fibers always being careful to ensure that no
nerve roots are in the vicinity. The annulus is then opened
sharply and a discectomy is performed making sure that all
work is done perfectly perpendicular to the floor. If the contral-
ateral annulus is ossified or ankylosed, a Cobb elevator can be
placed across the disc space and very carefully used to break the
ankylosis. This maneuver is the key in correcting coronal bal-
ance as it allows the disc space to level once the graft is placed.
After the discectomy is complete, an appropriate graft is
sized and then placed into the disc space. This is done under
fluoroscopic guidance to ensure that the graft does not go out
the other side of the disc space (Figs. 98.4A and B). Once the
graft is seated appropriately, the retractors are removed and
care is taken to ensure hemostasis. The abdominal wall is closed
in layers and the skin closed in the usual fashion.
Multiple levels can be addressed with this technique.
Depending on the orientation of the curvature, at least two disc
spaces can be addressed through a single incision. Another
incision can be made to access additional disc spaces.
Figure 98.3. The anterior one
third of the disc space is the ideal tar-
get for docking. The red X on the
illustration to the left shows this area.
The fluoro image on the right shows
an intraoperative view of this area with
the retractor system and interbody
device in place.
LWBK836_Ch98_p1021-1030.indd 1023
1023
POSTERIOR EXPOSURE METHODS
It is important to realize that minimally invasive does not always
mean the smallest incision. Instead, we are leveraging minimal
access technology to preserve the musculotendinous envelope.
The incision we use is a single midline incision. The incision
carried down through the subcutaneous tissue to the dorsal fas-
cia. We then elevate the subcutaneous tissue to expose the dor-
sal fascia far enough laterally to allow for transfascial,
transmuscular tubular retractors to be placed at each level.
This incision has several distinct advantages. The first is that
a single midline incision is cosmetically preferred to many
paired stab incisions. The second is that should difficulty arise,
conversion to an open procedure does not risk the penalty of
having two large paramidline incisions. The third is that elevat-
ing flaps above the facia reduces the working distance to the
spine by getting the subcutaneous tissues out of the way.
Minimally invasive tubular retractors placed using sequen-
tial dilation techniques are used to effect multiple ports for key-
hole exposure. After the incision is made and the subcutaneous
flaps are raised, attention is turned to placement of the tubular
retractors. In the lumbar spine, we generally use 4 cm from the
midline as entry points in the fascia. Alternatively, we have used
the lateral pedicle line or the midtransverse process line to
mark our entry point, depending on the patients size and
degree of deformity. Using fluoroscopy, each pedicle to be
instrumented is identified and the entry point is marked in the
dorsal fascia using bovie cautery. Of note, care must be taken
when using fluoroscopic guidance in a patient with rotational
deformity as this must be taken into account when planning
entry points as it is easy to be misled by a fluoroscopic image if
the underlying anatomy is not well understood. We expose one
level at a time, and two surgeons can work simultaneously on
either side of the spine. The fascia is opened 1 to 2 cm at the
previously defined entry point. Using blunt finger dissection,
the facet joint is palpated.
In the lumbar spine, we use tubular retractors placed using
sequential dilation. The first dilator is placed on the facet joint
and subsequent dilation takes place. As the dilators get larger,
they cup the joint and prevent dislodgement. Dilation is
checked with fluoroscopy to ensure that the correct facet is
being exposed and to ensure that no dislodgement has
occurred. Once the final tube is in place, it is locked to the
operating table using flexible retractor arms. This technique
provides excellent exposure of the facet complex and can
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 1024 Section VIII Adult Spinal Deformity

A B

Figure 98.4. Fluoro images of the graft placed in the disc space in the anteroposterior projection (A) and
lateral projection (B).

provide exposure of the lamina, pars, and the transverse pro-
cess with small movements of the retractor tube. Figure 98.5
shows a tubular retractor in place.
Smith-Petersen osteotomies can be performed once the
facet joint is exposed. The facet complex, pars, and inferior
lamina are cleared of any soft tissue. Using a high-speed drill,
the inferior articular process is removed and saved to use as
autologous bone graft. The tip of the superior articular process
is then drilled off down to the level of the ligamentum flavum.
The ligament is then resected using Kerrison rongeurs. If no
osteotomy is required, the facet joint can be arthrodesed to
effect a fusion across that level.
As the level progresses superiorly into the upper lumbar and
thoracic spine, the depth of retraction is reduced and it
becomes increasingly cumbersome to utilize tubular retractors
to effect exposure. If osteotomies are required, hand held
retractors can be used to bluntly dissect and retract the subfa-
cial muscle. We have found that various length nasal speculum
type retractors provide adequate exposure of the necessary
anatomy (Fig. 98.6). In the thoracic spine, the transverse pro-
cess is palpated and the speculum is used to bluntly dissect the
soft tissues off the spinous process. From this landmark, the
facet joint can be exposed for arthrodesis or Smith-Petersen
osteotomy. The pedicle entry zone can then be easily accessed.

Figure 98.5. A tubular retractor in place. Note that the facia is Figure 98.6. A nasal speculum is providing retraction of the nec-
intact and no paraspinal muscle dissection is undertaken. essary anatomy in the thoracic spine.

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 Chapter 98 Minimally Invasive Deformity Surgery: Future Directions 1025

PLACEMENT OF POSTERIOR
SEGMENTAL INSTRUMENTATION
Pedicle screws can be placed utilizing standard freehand or
fluoroscopic methods. If an osteotomy is to be performed at
the level of interest and exposure is already performed via
tubular retraction, we prefer to use an open freehand tech-
nique through the tubular retractor to cannulate the pedicle.
This technique is also useful if the local deformity does not
allow adequate fluoroscopic imaging of the pedicle of interest.
If no osteotomy is to be performed and arthrodesis is being
accomplished via an interbody fusion, then the pedicle screw is
placed using percutaneous fluoroscopic techniques.
If a retractor and open freehand technique is used, pedicle
cannulation proceeds as follows. The pedicle entry zone is
identified and local landmarks are visualized. A high-speed drill
is used to mark the entry point and drill through the outer cor-
tex to the cancellous bone of the pedicle. A pedicle probe is
then advanced into the pedicle (Fig. 98.7). The pedicle walls
are then checked for breeches. If no breech is present, a long
k-wire is then passed down the retractor and into the cannu-
lated tract. The retractor is then removed leaving the k-wire to Figure 98.8. Transfacially placed k-wires are in place at every level
to be instrumented.
mark the pedicle. The retractor is then moved to the next adja-
cent level. Extreme care must be taken not to dislodge the
k-wire. Figure 98.8 shows k-wires in place at each level.
After all the pedicles have been cannulated and k-wires
prevents the difficulty in having to manage many pairs of k-wires
placed, the pedicles are tapped and the pedicle screws are
in the operative field, which carries the risk of contamination,
placed over the k-wires. The pedicle screws are attached to
surgeon injury, and k-wire displacement.
screw extenders that allow for manipulation of the screws as
Once the pedicle screws are placed, rodding takes place.
well as for eventual rod placement (Fig. 98.9). Alternatively, the
Rodding can be difficult as many of the normal techniques for
pedicle screws can be placed as you go as soon as each level is
curve correction such as derotation and in situ bending are not
complete. Placing all of the k-wires first is sometimes of benefit
directly translatable to a minimal access approach. The rod
as the screw extenders can obscure access to the adjacent level
must be shaped to the appropriate lordosis and/or kyphosis
if the deformity is severe enough. Placing the screws as you go
and then is percutaneously passed through the pedicle screw
extenders (Fig. 98.10). The pedicle screw extenders can be uti-
lized to impart vector forces onto the pedicle screws to correct
the deformity to make rodding easier. The rod is then reduced

Figure 98.7. A Lenke pedicle probe can be used down the tubular Figure 98.9. Pedicle screw extenders are visible above the facia to
retractor to cannulate the pedicle. allow rodding and spinal column manipulation.

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 1026 Section VIII Adult Spinal Deformity

Operating Room and

Hospital Statistics in First
TABLE 98.1 10 Patients Undergoing
MIS Correction of
Deformity
Length of surgery 7.6 hr (4.512.5)
Length of ICU stay 30.25 hr (0168)
Length of hospital stay 7.1 d (315)
Estimated blood loss 260 cc (50600)
Transfusion 2/10
Major complications 0

and was improved to 9 (range 4 to 18). Mean preoperative

Figure 98.10. Rodding is performed by passing the rod percuta-
neously through each pedicle screw extender.
into the pedicle screw saddle using the screw extension devices
and locked to the pedicle screw using standard locking nuts.
Maintaining a lordosis is important as the rod is being
reduced. With the rod in a lordotic position, the vector forces
of reduction will try to place the rod in a kyphotic position.
Locking the rod down to at least one screw position before
removing the rod holder can help prevent this problem.
lordosis was 29 (range 42 to 5) and was improved to 31
(range 53 to 21) (Table 98.1). When sagittal balance was
normal preoperatively, it was maintained in two cases and made
slightly worse in two cases. When sagittal balance was abnormal
preoperatively, it was improved in six out of six cases. Coronal
balance was maintained normal in two of four cases and made
slightly worse in two of four cases. When it was abnormal pre-
operatively, it was improved in five of six cases and remained
unchanged in one of six cases. Finally, normal lumbar lordosis
was maintained in six of six cases, although one patient had
slightly less lordosis postoperatively compared with preopera-
tively. Preoperative kyphosis was improved in four of four cases
(Table 98.2). The following case examples are illustrative of the
cases currently being done using MIS technique.
CONCLUSION

ARTHRODESIS Minimally invasive techniques are new to the area of deformity

Arthrodesis is the cornerstone of any fusion. In a minimally
invasive setting, the large bony surface area normally exposed
is not present. Therefore, effective fusions rely on a combina-
tion of factors.
Arthrodesis is effected in several ways. Interbody fusions
performed via the direct lateral approach, via transforaminal
lumbar interbody fusion (TLIF) or via mini anterior lumbar
interbody fusion (ALIF) approaches are important methods
for solid fusion. This allows for a wide area of arthrodesis given
a large discectomy and appropriate preparation of the disc
space. Posteriorly, fusion takes place across the facet joints via
direct arthrodesis or across an area of osteotomy. The soft tis-
sues can be dissected superiorly and inferiorly to increase the
amount of fusion surface. Bone morphogenic protein is used as
an adjunct to improve the fusion rates.
correction. Indications for who should be considered are still
being developed. Questions including how effective these tech-
niques are at preventing adjacent segment failure in deformity
and what are the arthrodesis rates have yet to be answered.
Limitations of the technology for correcting large fixed curves
and for fusing long segments across the thoracolumbar junc-
tion to the sacrum need to be overcome.
However, these techniques are very powerful in correcting a
select number of carefully chosen curves that are flexible and
anatomically amenable to minimally invasive techniques. The
future of deformity surgery will include minimally invasive tech-
niques as a part of the armamentarium.
Early Results in First 10
TABLE 98.2 Patients Undergoing MIS
Correction of Deformity

EARLY RESULTS Preoperative Postoperative

Measure Value Value
Assessing the short-term outcomes in the first 10 patients
Cobb angle (mean/range) 26 (1140) 9 (418)
undergoing MIS correction of deformity revealed the follow-
Lordosis (mean/range) 29 (425) 31 (53 21)
ing. Mean preoperative Cobb angle was 26 (range 11 to 40)

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 Chapter 98 Minimally Invasive Deformity Surgery: Future Directions
CASE 98.1
The following case example is of a primary degenerative
lumbar curve. The patient is a 61-year-old woman with a pri-
mary complaint of severe low back pain and left-sided radic-
ulopathy. She was sagittally and coronally balanced on
standard 36-inch scoliosis X-rays (Figs. 98.11A and B). A
magnetic resonance imaging (MRI) of the lumbar spine
showed left-sided lateral recess stenosis from disc degenera-
tion and buckled ligamentum flavum at the L3/4 level.
Direct lateral interbody fusions were performed at L2/3,
L3/4, and L4/5 via a right-sided approach due to the curve.
This procedure provided good correction of her
A B
Figure 98.11. Case 98.1 preoperative anteroposterior (A) and
lateral (B) X-rays.
LWBK836_Ch98_p1021-1030.indd 1027
1027
significant coronal plane deformity. A posterior L2 to L5
posterior minimally invasive fusion was performed in the
same setting for posterior stabilization along with L2/3,
L3/4, and L4/5 Smith-Petersen osteotomies and bilateral
L3/4 foraminectomies for decompression and posterior
release. Estimated blood loss was 500 cc. Postoperative
X-rays show excellent correction of her lumbar curve with
preserved sagittal and coronal balance (Figs. 98.12A and B).
The patient had complete resolution of her radiculopathy
and back pain and was no longer taking pain medication at
the 3-month follow-up.
A B
Figure 98.12. Case 98.1 postoperative anteroposterior (A) and
lateral (B) X-rays.
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 1028 Section VIII Adult Spinal Deformity

CASE 98.2

This case is an example of late, painful progression of an
adolescent idiopathic scoliosis (AIS) thoracolumbar/lum-
bar Lenke type V curve treated with thoracolumbar direct
lateral fusions and instrumentation across the thoracolum-
bar junction. This is a 61-year-old woman with complaints of
back pain overlying her curve with a significant and trouble-
some rib hump and shoulder asymmetry. Her curve mea-
sured 36 T10 to L3 (Figs. 98.13A and B). On lateral
bending films, her compensatory lumbar and upper tho-
racic curves completely corrected (Figs. 98.13B and C).
This curve was treated posterior instrumentation T10 to L3
as a first stage. Smith-Petersen osteotomies were performed
at T11/12 through L1/2 for posterior release and arthrod-
esis. A second stage anterior procedure with direct lateral
interbody fusion at T12/L1, L1/2, and L2/3 was performed
for anterior column support and arthrodesis across the tho-
racolumbar junction. Estimated blood loss was 1000 cc. Her
residual curve across her Cobb levels is now 10. She has had
excellent cosmetic correction of her rib hump (Figs. 98.14A
and B). She has had good postoperative relief of her pain
7 months postoperatively with only intermittent use of any
pain medicine (two to three times per week).

A B C D

Figure 98.13. Case 98.2 preoperative anteroposterior (A) and lateral (B) and side bending (C and D)
X-rays. Note the relatively flexible nature of the curve on side bending X-rays.

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 Chapter 98 Minimally Invasive Deformity Surgery: Future Directions 1029

CASE 98.3

This is a case of a significant coronal and sagittal plane

deformity with the correction crossing the thoracolumbar
junction. This case illustrates how a carefully chosen patient
can benefit greatly from a minimally invasive approach.
This is a 76-year-old female with primary complaints of
severe low back pain stemming from her severe coronal
and sagittal plane deformity from progressive adult degen-
erative scoliosis. Her scoliotic curve measures 50 T11 to L4
(Fig. 98.15A). She stands in 10 cm of positive sagittal bal-
ance (Fig. 98.15B). Careful examination of her supine and
side bending films, however, show that her curve is quite
flexible (Figs. 98.15C and D). Anterior direct lateral fusions
were performed at T12/L1, L1/2, L3/4, and L4/5 as a first
stage. Of note, even though her curve was flexible, the
postoperative computed tomography (CT) after the first
stage did not show a significant coronal correction due to
ankylosis at the facet joints limiting the corrective action of
the direct lateral fusions (Fig. 98.16A). The patient was
instrumented and arthrodesed T10 to L5 in a second stage
with Smith-Petersen osteotomies at L1/2, L2/3, L3/4, and
L4/5. Very good coronal plane correction was achieved
after the second stage due to releases across the facet joints
(Fig. 98.16B). Excellent sagittal plane correction was also
A B
achieved due to a combination of anterior interbody grafts,
Figure 98.14. Case 98.2 postoperative anteroposterior (A) and lat- releases via osteotomies, reduction of the screws to the
eral (B) X-rays. rods, and patient positioning (Figs. 98.17A and B). The
L5/S1 interspace had a reasonable disc, and it was decided
to attempt to not fuse to the sacrum.

A B C D

Figure 98.15. Case 98.3 preoperative anteroposterior (A) and lateral (B) and side bending (C and D) X-rays.
Again note how the curve responds to postural changes.

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 1030 Section VIII Adult Spinal Deformity

A B
A B

Figure 98.16. Case 98.3 three-dimensional reconstructions of

postoperative computed tomography scans show minimal coronal
Figure 98.17. Case 98.3 postoperative anteroposterior (A) and lat-
eral (B) standing scoliosis X-rays showing correction of coronal and
plane correction after stage 1 direct lateral interbody fusion proce-
sagittal plane balance.
dure at multiple levels (A). Note after stage 2 posterior Smith-
Petersen osteotomies and dorsal instrumentation, much better
coronal balance is achieved due to release of the ankylosed facets (B).

5. Mayer TG, Vanharanta H, Gatchel RJ, et al. Comparison of CT scan muscle measurements
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