Modified Compact-Contact Pedicle Subtraction Osteotomy: Technique Description and Outcomes in a Retrospective Case Series
Abstract
Background: Pedicle subtraction osteotomy (PSO) is an established technique for correcting fixed sagittal plane deformities (FSPD), but it is associated with substantial blood loss and a risk of pseudarthrosis. This study aims to develop a modified PSO technique to treat FSPD and assess its technical efficacy and safety.
Methods: A retrospective review was conducted on patients with FSPD who underwent the modified PSO technique between 2004 and 2021. Radiographic outcomes were assessed using kyphotic angle and sagittal vertical axis (SVA), while clinical outcomes were evaluated using the visual analog scale (VAS) for back pain and the Oswestry Disability Index (ODI). Postoperative complications were assessed to evaluate the safety of the technique.
Results: Fifty-three patients (54.7% men) with a mean age of 34.5 years were included in the study, with a mean follow-up of 54.8 months. The mean intraoperative blood loss was 466.9 ± 252.9 ml. Postoperatively, the mean kyphotic angle improved significantly from 37.2° to 8.5° (P < 0.0001). At the final follow-up, a mean loss of correction of 6.4° was observed compared with the immediate postoperative measurement. Statistically significant improvements were observed in the SVA, ODI, and VAS between the preoperative and postoperative assessments (P < 0.0001 for all). Postoperative complications occurred in five patients (9.4%), including pseudarthrosis with rod breakage in two patients (3.8%). No intraoperative or early postoperative neurological complications were observed.
Conclusion: The modified compact-contact PSO technique was feasible and demonstrated favorable radiographic and clinical outcomes, with relatively limited estimated blood loss (EBL) in primary procedures and a low rate of pseudarthrosis. Prospective comparative studies are warranted.
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4. Si G, Qiu W, Shen Q, Wang Y, Li W, Yu M, et al. Mini-open Pedicle Subtraction Osteotomy versus Standard Posterior Approach for Ankylosing Spondylitis-related Spinal Kyphosis: A Comparative Study. Orthop Surg. 2023;15(10):2656-64. doi: 10.1111/os.13873. [PubMed: 37681279]. [PubMed Central: PMC10549849].
5. Bourghli A, Boissiere L, Chevillotte T, Huneidi M, Silvestre C, Abelin-Genevois K, et al. Radiographic outcomes and complications after L4 or L5 pedicle subtraction osteotomy for fixed sagittal malalignment in 102 adult spinal deformity patients with a minimum 2-year follow-up. Eur Spine J. 2022;31(1):104-11. doi: 10.1007/s00586-021-07008-7. [PubMed: 34586505].
6. Buell TJ, Nguyen JH, Mazur MD, Mullin JP, Garces J, Taylor DG, et al. Radiographic outcome and complications after single- level lumbar extended pedicle subtraction osteotomy for fixed sagittal malalignment: a retrospective analysis of 55 adult spinal deformity patients with a minimum 2-year follow-up. J Neurosurg Spine. 2019;30(2):242-52. doi: 10.3171/2018.7.Spine171367. [PubMed: 30497176].
7. Hyun SJ, Lenke LG, Kim YC, Koester LA, Blanke KM. Comparison of standard 2-rod constructs to multiple-rod constructs for fixation across 3-column spinal osteotomies. Spine (Phila Pa 1976). 2014;39(22):1899-904. doi: 10.1097/brs.0000000000000556. [PubMed: 25299168].
8. Lyu Q, Lau D, Haddad AF, Deviren V, Ames CP. Multiple-rod constructs and use of bone morphogenetic protein-2 in relation to lower rod fracture rates in 141 patients with adult spinal deformity who underwent lumbar pedicle subtraction osteotomy. J Neurosurg Spine. 2022;36(2):235-45. doi: 10.3171/2021.3.Spine201968. [PubMed: 34560633].
9. Ikenaga M, Shikata J, Takemoto M, Tanaka C. Clinical outcomes and complications after pedicle subtraction osteotomy for correction of thoracolumbar kyphosis. J Neurosurg Spine. 2007;6(4):330-6. doi: 10.3171/spi.2007.6.4.8. [PubMed: 17436922].
10. Kim KT, Suk KS, Cho YJ, Hong GP, Park BJ. Clinical outcome results of pedicle subtraction osteotomy in ankylosing spondylitis with kyphotic deformity. Spine (Phila Pa 1976). 2002;27(6):612-8. doi: 10.1097/00007632-200203150-00010. [PubMed: 11884909].
11. Murrey DB, Brigham CD, Kiebzak GM, Finger F, Chewning SJ. Transpedicular decompression and pedicle subtraction osteotomy (eggshell procedure): a retrospective review of 59 patients. Spine (Phila Pa 1976). 2002;27(21):2338-45. doi: 10.1097/00007632-200211010-00006. [PubMed: 12438981].
12. Koller H, Koller J, Mayer M, Hempfing A, Hitzl W. Osteotomies in ankylosing spondylitis: where, how many, and how much? Eur Spine J. 2018;27(Suppl 1):70-100. doi: 10.1007/s00586-017-5421-z. [PubMed: 29290050].
13. Qian BP, Jiang J, Qiu Y, Wang B, Yu Y, Zhu ZZ. Radiographical predictors for postoperative sagittal imbalance in patients with thoracolumbar kyphosis secondary to ankylosing spondylitis after lumbar pedicle subtraction osteotomy. Spine (Phila Pa 1976). 2013;38(26):E1669-75. doi: 10.1097/brs.0000000000000021. [PubMed: 24335637].
14. Huang JC, Qian BP, Qiu Y, Wang B, Yu Y. When Can One-level Pedicle Subtraction Osteotomy Obtain Satisfied Outcomes for Severe Thoracolumbar Kyphosis with Global Kyphosis ≥80° in Ankylosing Spondylitis: A Comparison with Two-level Pedicle Subtraction Osteotomy. Spine (Phila Pa 1976). 2021;46(6): E374-e83. doi: 10.1097/brs.0000000000003800. [PubMed: 33620182].
15. Qiao M, Qian BP, Zhao SZ, Qiu Y, Wang B, Jiang J. Clinical and Radiographic Results After Posterior Wedge Osteotomy for Thoracolumbar Kyphosis Secondary to Ankylosing Spondylitis: Comparison of Long and Short Segment. World Neurosurg. 2018;117:e475-e82. doi: 10.1016/j.wneu.2018.06.053. [PubMed: 29920395].
16. Xin Z, Zheng G, Huang P, Zhang X, Wang Y. Clinical results and surgery tactics of spinal osteotomy for ankylosing spondylitis kyphosis: experience of 428 patients. J Orthop Surg Res. 2019;14(1):330. doi: 10.1186/s13018-019-1371-y. [PubMed: 31640803]. [PubMed Central: PMC6805318].
17. Yagi M, King AB, Cunningham ME, Boachie-Adjei O. Long-term Clinical and Radiographic Outcomes of Pedicle Subtraction Osteotomy for Fixed Sagittal Imbalance: Does Level of Proximal Fusion Affect the Outcome? Minimum 5-Year Follow- up. Spine Deform. 2013;1(2):123-31. doi: 10.1016/j.jspd.2013.01.003. [PubMed: 27927428].
18. Hyun SJ, Rhim SC. Clinical outcomes and complications after pedicle subtraction osteotomy for fixed sagittal imbalancepatients: A long-term follow-up data. J Korean Neurosurg Soc. 2010;47(2):95-101. doi: 10.3340/jkns.2010.47.2.95. [PubMed: 20224706]. [PubMed Central: PMC2836458].
19. Menger RP, Davis DD, Bryant JH. Spinal Osteotomy. Treasure Island, FL: StatPearls Publishing; 2026.
20. Smith JS, Sansur CA, Donaldson WF, 3rd, Perra JH, Mudiyam R, Choma TJ, et al. Short-term morbidity and mortality associated with correction of thoracolumbar fixed sagittal plane deformity: a report from the Scoliosis Research Society Morbidity and Mortality Committee. Spine (Phila Pa 1976). 2011;36(12):958-64. doi: 10.1097/BRS.0b013e3181eabb26. [PubMed: 21192289].
21. Kim YJ, Bridwell KH, Lenke LG, Cheh G, Baldus C. Results of lumbar pedicle subtraction osteotomies for fixed sagittal imbalance: a minimum 5-year follow-up study. Spine (Phila Pa 1976). 2007;32(20):2189-97. doi: 10.1097/BRS.0b013e31814b8371. [PubMed: 17873810].
22. Gupta S, Eksi MS, Ames CP, Deviren V, Durbin-Johnson B, Smith JS, et al. A Novel 4-Rod Technique Offers Potential to Reduce Rod Breakage and Pseudarthrosis in Pedicle Subtraction Osteotomies for Adult Spinal Deformity Correction. Oper Neurosurg. 2018;14(4):449-56. doi: 10.1093/ons/opx151. [PubMed: 28973658]. [PubMed Central: PMC6057497].
23. Schwab F, Blondel B, Chay E, Demakakos J, Lenke L, Tropiano P, et al. The comprehensive anatomical spinal osteotomy classification. Neurosurgery. 2014;74(1):112-20; discussion 20. doi: 10.1227/NEU.0000000000000182o. [PubMed: 24356197].
24. Burkhard MD, Suter D, Sigrist B, Fuernstahl P, Farshad M, Spirig JM. Pedicle subtraction osteotomy with patient-specific instruments. N Am Spine Soc J. 2021;7:100075. doi: 10.1016/j.xnsj.2021.100075. [PubMed: 35141640]. [PubMed Central: PMC8820003].
2. Bridwell KH, Lewis SJ, Lenke LG, Baldus C, Blanke K. Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance. J Bone Joint Surg Am. 2003;85(3):454-63. doi: 10.2106/00004623-200303000-00009. [PubMed: 12637431].
3. Mummaneni PV, Dhall SS, Ondra SL, Mummaneni VP, Berven S. Pedicle subtraction osteotomy. Neurosurgery. 2008;63(3 Suppl):171-6. doi: 10.1227/01.Neu.0000325680.32776.82. [PubMed: 18812921].
4. Si G, Qiu W, Shen Q, Wang Y, Li W, Yu M, et al. Mini-open Pedicle Subtraction Osteotomy versus Standard Posterior Approach for Ankylosing Spondylitis-related Spinal Kyphosis: A Comparative Study. Orthop Surg. 2023;15(10):2656-64. doi: 10.1111/os.13873. [PubMed: 37681279]. [PubMed Central: PMC10549849].
5. Bourghli A, Boissiere L, Chevillotte T, Huneidi M, Silvestre C, Abelin-Genevois K, et al. Radiographic outcomes and complications after L4 or L5 pedicle subtraction osteotomy for fixed sagittal malalignment in 102 adult spinal deformity patients with a minimum 2-year follow-up. Eur Spine J. 2022;31(1):104-11. doi: 10.1007/s00586-021-07008-7. [PubMed: 34586505].
6. Buell TJ, Nguyen JH, Mazur MD, Mullin JP, Garces J, Taylor DG, et al. Radiographic outcome and complications after single- level lumbar extended pedicle subtraction osteotomy for fixed sagittal malalignment: a retrospective analysis of 55 adult spinal deformity patients with a minimum 2-year follow-up. J Neurosurg Spine. 2019;30(2):242-52. doi: 10.3171/2018.7.Spine171367. [PubMed: 30497176].
7. Hyun SJ, Lenke LG, Kim YC, Koester LA, Blanke KM. Comparison of standard 2-rod constructs to multiple-rod constructs for fixation across 3-column spinal osteotomies. Spine (Phila Pa 1976). 2014;39(22):1899-904. doi: 10.1097/brs.0000000000000556. [PubMed: 25299168].
8. Lyu Q, Lau D, Haddad AF, Deviren V, Ames CP. Multiple-rod constructs and use of bone morphogenetic protein-2 in relation to lower rod fracture rates in 141 patients with adult spinal deformity who underwent lumbar pedicle subtraction osteotomy. J Neurosurg Spine. 2022;36(2):235-45. doi: 10.3171/2021.3.Spine201968. [PubMed: 34560633].
9. Ikenaga M, Shikata J, Takemoto M, Tanaka C. Clinical outcomes and complications after pedicle subtraction osteotomy for correction of thoracolumbar kyphosis. J Neurosurg Spine. 2007;6(4):330-6. doi: 10.3171/spi.2007.6.4.8. [PubMed: 17436922].
10. Kim KT, Suk KS, Cho YJ, Hong GP, Park BJ. Clinical outcome results of pedicle subtraction osteotomy in ankylosing spondylitis with kyphotic deformity. Spine (Phila Pa 1976). 2002;27(6):612-8. doi: 10.1097/00007632-200203150-00010. [PubMed: 11884909].
11. Murrey DB, Brigham CD, Kiebzak GM, Finger F, Chewning SJ. Transpedicular decompression and pedicle subtraction osteotomy (eggshell procedure): a retrospective review of 59 patients. Spine (Phila Pa 1976). 2002;27(21):2338-45. doi: 10.1097/00007632-200211010-00006. [PubMed: 12438981].
12. Koller H, Koller J, Mayer M, Hempfing A, Hitzl W. Osteotomies in ankylosing spondylitis: where, how many, and how much? Eur Spine J. 2018;27(Suppl 1):70-100. doi: 10.1007/s00586-017-5421-z. [PubMed: 29290050].
13. Qian BP, Jiang J, Qiu Y, Wang B, Yu Y, Zhu ZZ. Radiographical predictors for postoperative sagittal imbalance in patients with thoracolumbar kyphosis secondary to ankylosing spondylitis after lumbar pedicle subtraction osteotomy. Spine (Phila Pa 1976). 2013;38(26):E1669-75. doi: 10.1097/brs.0000000000000021. [PubMed: 24335637].
14. Huang JC, Qian BP, Qiu Y, Wang B, Yu Y. When Can One-level Pedicle Subtraction Osteotomy Obtain Satisfied Outcomes for Severe Thoracolumbar Kyphosis with Global Kyphosis ≥80° in Ankylosing Spondylitis: A Comparison with Two-level Pedicle Subtraction Osteotomy. Spine (Phila Pa 1976). 2021;46(6): E374-e83. doi: 10.1097/brs.0000000000003800. [PubMed: 33620182].
15. Qiao M, Qian BP, Zhao SZ, Qiu Y, Wang B, Jiang J. Clinical and Radiographic Results After Posterior Wedge Osteotomy for Thoracolumbar Kyphosis Secondary to Ankylosing Spondylitis: Comparison of Long and Short Segment. World Neurosurg. 2018;117:e475-e82. doi: 10.1016/j.wneu.2018.06.053. [PubMed: 29920395].
16. Xin Z, Zheng G, Huang P, Zhang X, Wang Y. Clinical results and surgery tactics of spinal osteotomy for ankylosing spondylitis kyphosis: experience of 428 patients. J Orthop Surg Res. 2019;14(1):330. doi: 10.1186/s13018-019-1371-y. [PubMed: 31640803]. [PubMed Central: PMC6805318].
17. Yagi M, King AB, Cunningham ME, Boachie-Adjei O. Long-term Clinical and Radiographic Outcomes of Pedicle Subtraction Osteotomy for Fixed Sagittal Imbalance: Does Level of Proximal Fusion Affect the Outcome? Minimum 5-Year Follow- up. Spine Deform. 2013;1(2):123-31. doi: 10.1016/j.jspd.2013.01.003. [PubMed: 27927428].
18. Hyun SJ, Rhim SC. Clinical outcomes and complications after pedicle subtraction osteotomy for fixed sagittal imbalancepatients: A long-term follow-up data. J Korean Neurosurg Soc. 2010;47(2):95-101. doi: 10.3340/jkns.2010.47.2.95. [PubMed: 20224706]. [PubMed Central: PMC2836458].
19. Menger RP, Davis DD, Bryant JH. Spinal Osteotomy. Treasure Island, FL: StatPearls Publishing; 2026.
20. Smith JS, Sansur CA, Donaldson WF, 3rd, Perra JH, Mudiyam R, Choma TJ, et al. Short-term morbidity and mortality associated with correction of thoracolumbar fixed sagittal plane deformity: a report from the Scoliosis Research Society Morbidity and Mortality Committee. Spine (Phila Pa 1976). 2011;36(12):958-64. doi: 10.1097/BRS.0b013e3181eabb26. [PubMed: 21192289].
21. Kim YJ, Bridwell KH, Lenke LG, Cheh G, Baldus C. Results of lumbar pedicle subtraction osteotomies for fixed sagittal imbalance: a minimum 5-year follow-up study. Spine (Phila Pa 1976). 2007;32(20):2189-97. doi: 10.1097/BRS.0b013e31814b8371. [PubMed: 17873810].
22. Gupta S, Eksi MS, Ames CP, Deviren V, Durbin-Johnson B, Smith JS, et al. A Novel 4-Rod Technique Offers Potential to Reduce Rod Breakage and Pseudarthrosis in Pedicle Subtraction Osteotomies for Adult Spinal Deformity Correction. Oper Neurosurg. 2018;14(4):449-56. doi: 10.1093/ons/opx151. [PubMed: 28973658]. [PubMed Central: PMC6057497].
23. Schwab F, Blondel B, Chay E, Demakakos J, Lenke L, Tropiano P, et al. The comprehensive anatomical spinal osteotomy classification. Neurosurgery. 2014;74(1):112-20; discussion 20. doi: 10.1227/NEU.0000000000000182o. [PubMed: 24356197].
24. Burkhard MD, Suter D, Sigrist B, Fuernstahl P, Farshad M, Spirig JM. Pedicle subtraction osteotomy with patient-specific instruments. N Am Spine Soc J. 2021;7:100075. doi: 10.1016/j.xnsj.2021.100075. [PubMed: 35141640]. [PubMed Central: PMC8820003].
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| Issue | Vol 12 No 4 (2026) | |
| Section | Research Articles | |
| Keywords | ||
| Deformities Osteotomy Surgical Technique Outcomes | ||
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How to Cite
1.
Safaei S, Yazdanian T, Azimi P. Modified Compact-Contact Pedicle Subtraction Osteotomy: Technique Description and Outcomes in a Retrospective Case Series. J Orthop Spine Trauma. 2026;12(4):190-6.
