European Spine Journal

, Volume 28, Issue 1, pp 121–126 | Cite as

Sagittal imbalance treated with L5 pedicle subtraction osteotomy with short lumbar fusion from L4 to sacrum using four screws into L4 for enhanced fixation two additional vertebral screws: a technical note

  • Kuenzang Wangdi
  • Bungo OtsukiEmail author
  • Shunsuke Fujibayashi
  • Shimei Tanida
  • Kazutaka Masamoto
  • Shuichi Matsuda
Ideas and Technical Innovations



To report on suggested technique with four screws in a single vertebra (two pedicle screws and two direct vertebral body screws) for enhanced fixation with just one level cranially to a pedicle subtraction osteotomy (PSO).


A 60-year-old woman underwent L4/5 fusion surgery for degenerative spondylolisthesis. Two years later, she was unable to stand upright even for a short time because of lumbar kyphosis caused by subsidence of the fusion cage and of Baastrup syndrome in the upper lumbar spine [sagittal vertical axis (SVA) of 114 mm, pelvic incidence of 75°, and lumbar lordosis (LL) of 41°]. She underwent short-segment fusion from L4 to the sacrum with L5 pedicle subtraction osteotomy. We reinforced the construct with two vertebral screws at L4 in addition to the conventional L4 pedicle screws.


After the surgery, her sagittal parameters were improved (SVA, 36 mm; LL, 54°). Two years after the corrective surgery, she maintained a low sagittal vertical axis though high residual pelvic tilt indicated that the patient was still compensating for residual sagittal misalignment.


PSO surgery for sagittal imbalance usually requires a long fusion at least two levels above and below the osteotomy site to achieve adequate stability and better global alignment. However, longer fixation may decrease the patients’ quality of life and cause a proximal junctional failure. Our novel technique may shorten the fixation area after osteotomy surgery.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.


Sagittal imbalance Pedicle subtraction osteotomy Baastrup syndrome Vertebral screw Four-rod construct 



No funds were receive in support of this work.

Compliance with ethical standards

Conflict of interest

No conflict of interest is declared.

Supplementary material

586_2018_5487_MOESM1_ESM.pptx (1.1 mb)
Supplementary material 1 (PPTX 1080 kb)


  1. 1.
    Angevine PD, Bridwell KH (2006) Sagittal imbalance. Neurosurg Clin N Am 17:353–363. CrossRefGoogle Scholar
  2. 2.
    Roussouly P, Gollogly S, Berthonnaud E, Dimnet J (2005) Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine (Phila Pa 1976) 30:346–353CrossRefGoogle Scholar
  3. 3.
    Diebo BG, Henry J, Lafage V, Berjano P (2015) Sagittal deformities of the spine: factors influencing the outcomes and complications. Eur Spine J 24(Suppl 1):S3–S15. CrossRefGoogle Scholar
  4. 4.
    Burch S (2007) Surgical complications of spinal deformity surgery. Neurosurg Clin N Am 18:385–392. CrossRefGoogle Scholar
  5. 5.
    Pateder DB, Park YS, Kebaish KM, Cascio BM, Buchowski JM, Song EW, Shapiro MB, Kostuik JP (2006) Spinal fusion after revision surgery for pseudarthrosis in adult scoliosis. Spine (Phila Pa 1976) 31:E314–E319. CrossRefGoogle Scholar
  6. 6.
    Kimura H, Fujibayashi S, Otsuki B, Takahashi Y, Nakayama T, Matsuda S (2016) Effects of lumbar stiffness after lumbar fusion surgery on activities of daily living. Spine (Phila Pa 1976) 41:719–727. CrossRefGoogle Scholar
  7. 7.
    Fujimori T, Okuda S, Iwasaki M, Yamasaki R, Maeno T, Yamashita T, Matsumoto T, Wada E, Oda T (2016) Validity of the Japanese Orthopaedic Association scoring system based on patient-reported improvement after posterior lumbar interbody fusion. Spine J. Google Scholar
  8. 8.
    Filippiadis DK, Mazioti A, Argentos S, Anselmetti G, Papakonstantinou O, Kelekis N, Kelekis A (2015) Baastrup’s disease (kissing spines syndrome): a pictorial review. Insights Imaging 6:123–128. CrossRefGoogle Scholar
  9. 9.
    Singla A, Shankar V, Mittal S, Agarwal A, Garg B (2014) Baastrup’s disease: the kissing spine. World J Clin Cases 2:45–47. CrossRefGoogle Scholar
  10. 10.
    Gelb DE, Lenke LG, Bridwell KH, Blanke K, McEnery KW (1995) An analysis of sagittal spinal alignment in 100 asymptomatic middle and older aged volunteers. Spine (Phila Pa 1976) 20:1351–1358CrossRefGoogle Scholar
  11. 11.
    Kobayashi T, Atsuta Y, Matsuno T, Takeda N (2004) A longitudinal study of congruent sagittal spinal alignment in an adult cohort. Spine (Phila Pa 1976) 29:671–676CrossRefGoogle Scholar
  12. 12.
    Barrey C, Roussouly P, Perrin G, Le Huec JC (2011) Sagittal balance disorders in severe degenerative spine. Can we identify the compensatory mechanisms? Eur Spine J 20(Suppl 5):626–633. CrossRefGoogle Scholar
  13. 13.
    Odate S, Shikata J, Kimura H, Soeda T (2013) Sacral fracture after instrumented lumbosacral fusion: analysis of risk factors from spinopelvic parameters. Spine (Phila Pa 1976) 38:E223–E229. CrossRefGoogle Scholar
  14. 14.
    Tsuchiya K, Bridwell KH, Kuklo TR, Lenke LG, Baldus C (2006) Minimum 5-year analysis of L5–S1 fusion using sacropelvic fixation (bilateral S1 and iliac screws) for spinal deformity. Spine (Phila Pa 1976) 31:303–308. CrossRefGoogle Scholar
  15. 15.
    Cheh G, Bridwell KH, Lenke LG, Buchowski JM, Daubs MD, Kim Y, Baldus C (2007) Adjacent segment disease following lumbar/thoracolumbar fusion with pedicle screw instrumentation: a minimum 5-year follow-up. Spine (Phila Pa 1976) 32:2253–2257. CrossRefGoogle Scholar
  16. 16.
    Lamartina C, Berjano P (2014) Classification of sagittal imbalance based on spinal alignment and compensatory mechanisms. Eur Spine J 23:1177–1189. CrossRefGoogle Scholar
  17. 17.
    Bradford DS (1988) Closed reduction of spondylolisthesis. An experience in 22 patients. Spine (Phila Pa 1976) 13:580–587CrossRefGoogle Scholar
  18. 18.
    Bridwell KH, Lewis SJ, Lenke LG, Baldus C, Blanke K (2003) Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance. J Bone Jt Surg Am 85-A:454–463CrossRefGoogle Scholar
  19. 19.
    Yilgor C, Sogunmez N, Boissiere L, Yavuz Y, Obeid I, Kleinstuck F, Perez-Grueso FJS, Acaroglu E, Haddad S, Mannion AF, Pellise F, Alanay A, European Spine Study G (2017) Global Alignment and Proportion (GAP) Score: development and validation of a new method of analyzing spinopelvic alignment to predict mechanical complications after adult spinal deformity surgery. J Bone Jt Surg Am 99:1661–1672. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Orthopaedic Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
  2. 2.Department of Orthopaedic SurgeryJigme Dorji Wangchuck National Referral HospitalThimphuBhutan

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