Sacropelvic Fixation Research Articles

A novel approach to navigated implantation of S-2 alar iliac screws using inertial measurement units.

The authors report on a novel method of intraoperative navigation with inertial measurement units (IMUs) for implantation of S-2 alar iliac (S2AI) screws in sacropelvic fixation of the human spine and its application in cadaveric specimens. Screw trajectories were planned on a multiplanar reconstruction of the preoperative CT scan. The pedicle finder and screwdriver were equipped with IMUs to guide the axial and sagittal tilt angles of the planned trajectory, and navigation software was developed. The entry points were chosen according to anatomical landmarks on the exposed spine. After referencing, the sagittal and axial orientation of the pedicle finder and screwdriver were wirelessly monitored on a computer screen and aligned with the preoperatively planned tilt angles to implant the S2AI screws. The technique was performed without any intraoperative imaging. Screw positions were analyzed on postoperative CT scans. Seventeen of 18 screws showed a good S2AI screw trajectory. Compared with the postoperatively measured tilt angles of the S2AI screws, the IMU readings on the screwdriver were within an axial plane deviation of 0° to 5° in 15 (83%) and 6° to 10° in 2 (11%) of the screws and within a sagittal plane deviation of 0° to 5° in 15 (83%) and 6° to 10° in 3 (17%) of the screws. IMU-based intraoperative navigation may facilitate accurate placement of S2AI screws.

Camptocormia and Dropped Head Syndrome Induced by Chemoradiotherapy for Base Tongue Carcinoma: A Case Report and Review of Literature

Introduction Camptocormia (bent spine syndrome) is an acquired postural disease characterized by forward flexion of the thoracolumbar spine. Camptocormia leads to lumbar kyphosis and increases during walking or standing. Management of Camptocormia is still a challenge and the literature on this topic is limited. There is no specific pharmacologic treatment for primary axial myopathy. Patients and Methods Our patient is a 68-year-old man, diagnosed in 2009 with a base tongue squamous cell carcinoma, surgically removed in September 2010. By May 2011, it was diagnosed with local recurrence, submitted to radiosensitive chemotherapy, and followed by radical radiotherapy 35 fractions of 70 Gy. Results After general anesthesia, and neuromonitoring a median incision was made from C3 to the sacrum, former instrumentation C3–T3 were tested, and no loosening or breakage was detected. Pedicle screws were inserted by free hand technic except C7 and T1 because the small space for rod connectors and T6, T10, L2, and L5 were osteotomies were performed total of 28 screws until S2 with sacropelvic fixation. In T6 and T10, Ponte osteotomies were made, and closing wedge pedicle subtraction in L2 and laminectomy of L3. Patient presented good outcome, receiving discharge at 7th postoperatory day, and initiated naturotherapy, fonotherapy, and physiotherapy, and nasoenteral catheter were maintained until 3 weeks and some swallowing improvement reported by the 6th week. In the follow-up, patient maintained satisfied with procedure and returned to work by 3rd month, screening showed no recurrence of the tumor or distant metastasis. Conclusion This is the first case described where dropped head syndrome and camptocormia occurred in the same patient because of radiosensibilizing chemotherapy for a nasopharyngeal carcinoma. We only found a single case report of a patient with dropped head syndrome associated with chemoradiotherapy for a nasopharyngeal carcinoma in a 59-year-old Japanese patient, described by Hashimoto (2012), treated without surgery who developed symptoms 2 years after chemoradiotherapy.

The Fate of L5–S1 with Low Dose BMP-2 and Pelvic Fixation in Adult Deformity Surgery

Introduction Pseudarthrosis at L5–S1 is one of the most common complications of long fusions to the sacrum in adult deformity surgery. Strategies for decreasing pseudarthrosis include interbody fusion, use of BMP-2 at the lumbosacral junction, and the use of sacropelvic fixation, individually or in combination. High-dose BMP-2 (20–40 mg) placed posterolaterally has shown comparable fusion rates to interbody fusion. The purpose of this study was to evaluate L5–S1 fusion rates when lower dose BMP-2 (average 3.2 mg) and pelvic fixation were used, with or without interbody fusion. Materials and Methods This is a retrospective review of 61 consecutive patients with a minimum follow-up of 2 years at a single institution. All patients had an isolated posterior approach, ≥ 5 levels fused including L5–S1, use of pelvic fixation, and no previous L5–S1 procedures. The patients were divided into two groups for comparison based on the use of an interbody cage/fusion at the L5–S1 level. Radiographic union was assessed by three independent reviewers using Bridwell criteria. Revision rates and implant-related complications were also reported. Results The fusion rate at L5–S1 was 97% (59/61) with no difference between the interbody and no interbody fusion groups (97 vs. 96%, p = 1.0). The overall revision rate for L5–S1 nonunion was 1.6%. The mean amount of BMP-2 used in the interbody group was 4.1 mg (2–10), 2.5 mg (0–8) in the disc space, and 1.6 mg (0–4) in the interbody cage, while there was no difference in the amount of rhBMP-2 placed posterolaterally between the two groups (IF = 1.6 vs. NIF = 2.0 mg, p = 0.08) along with autograft and allograft. There were no significant differences in the radiographic parameters or deformity correction between the groups. Conclusion The use of low dose of BMP-2 at the L5–S1 level in combination with sacropelvic fixation achieved satisfactory outcomes in adult deformity surgery. No additional radiologic or clinical benefit was realized with the addition of an interbody fusion at the L5–S1 level.

Sacro-Pelvic Fixation Using the S2 Alar-Iliac (S2AI) Screws in Adult Deformity Patients: Experiences with O-Arm/Stealth Navigation versus Robotic Guidance

Sacro-Pelvic Fixation Using the S2 Alar-Iliac (S2AI) Screws in Adult Deformity Patients: Experiences with O-Arm/Stealth Navigation versus Robotic Guidance

The Fate of L5-S1 with Low Dose BMP-2 and Pelvic Fixation in Adult Deformity Surgery

Pseudarthrosis at the L5-S1 level is one of the most common complications of long fusions to the sacrum in adult deformity patients. Strategies for decreasing non-union rates include interbody fusion and cage, use of high-dose BMP at the lumbo-sacral junction, and the use of sacro-pelvic fixation. A recent study found comparable fusion rates with interbody fusion or high-dose BMP posterolaterally. Further questions arise as to whether sacro-pelvic fixation and lower-dose BMP can also supplant the use of interbody fusion.

Sacropelvic fixation in adult spinal deformity (ASD); a very high rate of mechanical failure.

Sacropelvic fixation (SPF) is an integral part of ASD surgery. Literature suggests that combination of S1 and iliac screws may be associated with lowest rate of complications. To analyze the rate and potential factors of mechanical failure associated with SPF in adult spinal deformity surgery. Of 504 patients enrolled in a prospective multicentric database, 239 were treated conservatively and 265 were treated surgically. Forty-five of those who had sacroiliac fixations and with >6 months (or to failure) f/up constitute the population. Type of iliac fixation was S2 alar/iliac (S2AI) screws in 20 (44.4%) and iliac screws with lateral connectors (IwL) in 25 (55.6%). Diagnoses were degenerative in 20, failed back in 11 and other in 14. Average instrumentation length was 11.6 ± 4.0 levels. Cases with failure were compared to those without using Fisher's Exact and Mann-Whitney U tests. A total of 16 implant related complications were identified (35.6%). Failures were identified on an average of 224.1 days (8-709) following index surgery. Failure rate of S2AI screws was 35 vs. 12% for IwL screws (p > 0.05). All broken screws were associated with S2AI technique with polyaxial screws. Comparison of failed cases to others revealed that failed cases had inadequate restoration of Lumbar Lordosis but this was not statistically insignificant. Only age was a significantly different, patient with failure being older. Pelvic fixation is still associated with a very high rate of mechanical failure. Major risk factors appear to be age and type of fixation. Although could not be shown to be statistically significant, failure to restore the optimal sagittal balance may be a contributing factor as well. So in conclusion, in cases with suboptimal sagittal plane correction, S2AI with polyaxial screws seem to have higher risk of short-term acute failure compared to IwL.

Correction of severe pelvic obliquity using maximum-width segmental sacropelvic screw fixation: an analysis of 20 neuromuscular scoliosis patients.

The present study was a retrospective analysis. The purpose of the study was to evaluate the safety and efficacy of the maximum-width (M-W) segmental sacropelvic fixation technique, comprising iliac screws and/or iliosacral pedicle screws, to correct severe pelvic obliquity. Classic spinal fixation using the Luque-Galveston procedure for the correction of neuromuscular scoliosis may be inadequate to manage severe pelvic obliquities. A series of 20 consecutive patients with severe neuromuscular spinopelvic deformities was reviewed by an independent observer. Coronal and sagittal Cobb angle, frontal pelvic obliquity, and trunk shift were measured preoperatively, immediately postoperatively and at final follow-up. All 20 patients underwent spinal fusion with instrumentation extending to the pelvis. Fourteen cases had primary operations, and six patients had undergone previous spinal fusion above the pelvis, requiring extension to the pelvis. The mean age of the patients at surgery was 13 years, and the mean duration of the follow-up period was 36 months. The mean preoperative Cobb angle was 84° (range 56°-135°), which was corrected to a mean of 41° (range 8°-75°) postoperatively. At the final follow-up, the mean spinal curve remained at 42° (range 10°-75°). The mean preoperative pelvic obliquity was 42° (range 15°-105°), which was corrected by 78 % to 9° (range 0°-49°) postoperatively, with a pelvic obliquity of 10° (range 2°-49°) at final follow-up. Comparing the results of the present study with results in the literature describing the Luque-Galveston or unit rod techniques, despite patients in the present study having a greater mean pelvic obliquity (42° compared with 21° in the literature), a 78 % correction was still achieved, which is similar and, in certain instances, superior to the results of other published case series (78 % compared with 53 %). Maximum-width (M-W) segmental sacropelvic fixation, comprising iliosacral screws and/or iliac screws, enables a superior correction of severe pelvic obliquity in patients with neuromuscular scoliosis.

Unilateral versus bilateral iliac screws for spinopelvic fixation: are two screws better than one?

Long-segment spinal instrumentation ending at the sacrum places substantial biomechanical stress on sacral screws. Iliac (pelvic) screws relieve some of this stress by supplementing the caudal fixation. It remains an open question whether there is any clinically significant difference in sacropelvic fixation with bilateral versus unilateral iliac screws. The primary purpose of this study was to compare clinical and radiographic complications in the use of bilateral versus unilateral iliac screw fixation. The authors retrospectively reviewed 102 consecutive spinal fixation cases that extended to the pelvis at a single institution (University of California, San Francisco) in the period from 2005 to 2012 performed by the senior authors. Charts were reviewed for the following complications: reoperation, L5-S1 pseudarthrosis, sacral insufficiency fracture, hardware prominence, iliac screw loosening, and infection. The t-test, Pearson chi-square test, and Fisher exact test were used to determine statistical significance. The mean follow-up was 31 months. Thirty cases were excluded: 12 for inadequate follow-up, 15 for lack of L5-S1 interbody fusion, and 3 for preoperative osteomyelitis. The mean age among the 72 remaining cases was 62 years (range 39-79 years). Forty-six patients underwent unilateral and 26 bilateral iliac screw fixation. Forty-one percent (n = 19) of the unilateral cases and 50% (n = 13) of the bilateral cases were treated with reoperation (p = 0.48). In addition, 13% (n = 6) of the unilateral and 19% (n = 5) of the bilateral cases developed L5-S1 pseudarthrosis (p = 0.51). There were no sacral insufficiency fractures. Thirteen percent (n = 6) of the unilateral and 7.7% (n = 2) of the bilateral cases developed postoperative infection (p = 0.70). In a retrospective single-institution study, single versus dual pelvic screws led to comparable rates of reoperation, iliac screw removal, postoperative infection, pseudarthrosis, and sacral insufficiency fractures. For spinopelvic fixation, placing bilateral (vs unilateral) pelvic screws produced no added clinical benefit in most cases.

Sacropelvic fixation versus fusion to the sacrum for spondylodesis in multilevel degenerative spine disease

Retrospective study. For successful multilevel correction and stabilization of degenerative spinal deformities, a rigid basal construct to the sacrum is indispensable. The primary objective of this study was to compare the results of two different sacropelvic fixation techniques to conventional stabilization to the sacrum in patients with multilevel degenerative spine disease. A total of 69 patients with multisegmental fusion surgery (mean number of stabilized functional spinal units: 7.0±3.3) with a minimum of 1-year follow-up were included. 32 patients received fixation to the sacrum (S1), 23 patients received S1 and iliac screw fixation (iliac) and 14 patients were treated with iliosacral plate fixation (plate). Primary outcome parameters were radiographic outcome concerning fusion in the segment L5-S1, rate of screw loosening, back and buttock pain reduction [numeric rating scale for pain evaluation: 0 indicating no pain, 10 indicating the worst pain], overall extent of disability after surgery (Oswestry Disability Index) and the number of complications. The three groups did not differ in body mass index, ASA score, the number of stabilized functional spinal units, duration of surgery, the number of previous spine surgeries, or postoperative complication rate. The incidence of L5-S1 pseudarthrosis after 1year in the S1, iliac, and plate groups was 19, 0, and 29%, respectively (p<0.05 iliac vs. plate). The incidence of screw loosening after 1year in the S1, iliac, and plate groups was 22, 4, and 43%, respectively (p<0.05 iliac vs. plate). Average Oswestry scores after 1year in the S1, iliac, and plate groups were 40±18, 42±20, and 58±18, respectively (p<0.05 both S1 and iliac vs. plate). The surgical treatment of multilevel degenerative spine disease carries a significant risk for pseudarthrosis and screw loosening, mandating a rigid sacropelvic fixation. The use of an iliosacral plate resulted in an inferior surgical and clinical outcome when compared to iliac screws.

Comparison of TLIF With rhBMP-2 Versus No TLIF and Higher Posterolateral rhBMP-2 Dose At L5–S1 for Long Fusions to the Sacrum With Sacropelvic Fixation in Patients With Primary Adult Deformity

Comparvative case series. Data was prospectively entered and retrospectively analyzed. To evaluate the need for distal lumbar interbody fusion when sufficient recombinant human bone morphogenetic protein-2 (rhBMP-2) is used posterolaterally at L5-S1 in long spinal constructs for adult deformity via costs and radiographical and patient-reported outcome comparisons. Many authors and investigators have suggested that an interbody fusion is mandatory at L5-S1 with long fusion to the sacrum with sacropelvic fixation. Past studies have shown competitive fusion rates using rhBMP-2 versus iliac crest bone graft for long fusions. There are various advocates for anterior lumbar interbody fusion versus posterior lumbar interbody fusion versus transforaminal lumbar interbody fusion (TLIF). The optimal strategy remains elusive. Fifty-seven patients were studied at one institution. Thirty-one patients had no interbody fusion (NI group) with 20 mg of rhBMP-2 posterolaterally on 10 mL of carrier and 26 patients had TLIF at L5-S1 (TLIF group) with 6 mg of rhBMP-2 in the interbody space along with local bone graft and 6 mg of rhBMP-2 on carrier posterolaterally at L5-S1. Patients were followed for 24 to 87 months (mean follow-up, 3.92 yr). Demographics of the 2 groups were similar. There were no detected nonunions at L5-S1 in either group. By our limited cost analysis, the expense of performing a TLIF at L5-S1 is higher than that of using extra rhBMP-2 posterolaterally at that segment. Improvement in outcomes scores, namely Scoliosis Research Society-22 and Oswestry Disability Index, were the same statistically in both groups. Blood loss was greater in the TLIF group than the NI group. There were no identified rhBMP-2 adverse events in either group. Utilization of 20 mg of rhBMP-2 at L5-S1 has the potential to be less expensive than an interbody fusion in most patients having a primary long fusion for adult spinal deformity. The apparent fusion rates at L5-S1 were identical in both groups. Both strategies were successful in regard to improving patient outcomes and achieving apparent solid arthrodesis at the lumbosacral junction, which was the focus of this study. 2.

The result of S1 double screw fixation in patients not suited for L4 and/or L5 pedicle screw insertion

Variable methods are available for sacropelvic fixation. The usefulness of S1 double screw fixation for deformity surgery is established, but its effectiveness in cases where the L4 and/or L5 pedicle screw is not appropriate has not been reported. We reviewed medical records to identify long-segment, lumbar spine fixation involving S1 double screws. Nine such patients were treated between November 2006 and November 2012 at our center: all patients had infectious spondylitis involving L4 and/or L5. Two patients were excluded due to a limited follow-up period (< 6 months). The remaining seven patients were enrolled. We used dynamic X-rays or three-dimensional computed tomography (3D-CT) to assess any change in the lumbar alignment angle and to evaluate bony fusion with the graft material. The mean observation period of the seven patients was 16.9 months (range: 6-25). The mean age was 63.43 years (range: 55-73). Four patients were women. The average number of fusion levels was 3.5 ± 1.1. The ideal positioning and maintenance of the S1 double screws and bony fusion with the graft materials were confirmed using serial imaging. Lordosis in the lumbar region was immediately restored after surgery (27.0 ° ± 10.4 to 35.1 ° ± 10.7), and maintained with slight decrease (31.6 ° ± 8.8) throughout the follow-up period. S1 double screws provided stability when L4 and/or L5 pedicle screw fixation was not possible. Our results suggest that S1 double screws are a viable option for sacropelvic fixation in selected patients.

Transsacral transvertebral screw fixation and posterolateral fusion for spondyloptosis in an adolescent

Spondyloptosis is a condition in which the L5 vertebral body dislocates completely from the sacrum anteriorly and descends into the pelvis. Surgical options include posterior and anterior fusion, single- or two-stage operation, and neural decompression. We performed a one-stage operation on an adolescent with spondyloptosis by using an L2–S1 ilium posterior fusion with pedicle screws, cement augmentation, transsacral transvertebral screw fixation (L5–S1), and sacropelvic fixation for an adolescent with spondyloptosis. The clinical result was satisfactory and demonstrated that transsacral transvertebral screw fixation provides a safe and reliable in situ fixation of spondyloptosis.

Pelvic fixation for adult scoliosis

Obtaining a fusion, especially to the sacrum for adult deformity correction remains a challenge. Prior to modern fixation techniques, the reported fusion rates for adult scoliotic deformities were low. However sacropelvic fixation techniques for adult deformity continue to evolve. As a result, modern day pelvic fixation techniques have improved fusion rates at the base of long constructs. The purpose of this article is to discuss the history, indications, and modern fixation techniques for pelvic fixation in the surgical management of adult scoliosis patients. We searched PUBMED using the search terms pelvic fixation, deformity, lumbopelvic, sacropelvic, and iliac fixation. Linkage or association studies published in English and available full-text were analyzed specifically regarding techniques and innovations in pelvic fixation. Sacropelvic fixation should be considered in any patient with a long construct ending in the sacrum, those patients with associated risk factors for loss of distal fixation or high risk for pseudarthrosis at L5-S1, and those undergoing three column osteotomies or vertebral body resections in the low lumbar spine. Current pelvic fixation techniques with iliac screws, multiple screw/rod constructs, and S2-alar-iliac screws are all viable techniques for achieving pelvic fixation. There is growing evidence that pelvic fixation may become the standard for obtaining long fusions in adult scoliosis. Although technically challenging, in selected cases the use of four pelvic screws and/or four rods across the lumbosacral pelvis can help address pseudarthroses, implant breakage, and screw pullout secondary to osteoporosis. Ultimately, indications and techniques should be individualized to the patient and based on surgeon preference and experience.

Outcomes and Complications of Sacropelvic Fixation Using S2 Alar-Iliac (S2AI) Fixation in Adult Deformity Patients Fused to the Sacrum: A Prospective Study with Minimum Two-Year Follow-Up

Adult deformity patients requiring long posterior fusions to the sacrum often require supplemental pelvic fixation in order to avoid fixation failure and nonunion. There are many techniques available for fixation to the pelvis, some are technically difficult & require complex connectors, and separate incisions.

Outcome and Complications of Sacropelvic Fixation Using S2 Alar-Iliac (S2AI) Fixation in Adult Deformity Patients Fused to the Sacrum: A Prospective Study with Minimum Five-Year Follow-Up

Outcome and Complications of Sacropelvic Fixation Using S2 Alar-Iliac (S2AI) Fixation in Adult Deformity Patients Fused to the Sacrum: A Prospective Study with Minimum Five-Year Follow-Up

Clinical Incidence of Sacroiliac Joint Arthritis and Pain after Sacropelvic Fixation for Spinal Deformity

PurposeSacroiliac fixation using iliac screws for highly unstable lumbar spine has been reported with an improved fusion rate and clinical results. On the other hand, there is a potential for clinical problems related to iliac fixation, including late sacroiliac joint arthritis and pain.Materials and MethodsTwenty patients were evaluated. Degenerative scoliosis was diagnosed in 7 patients, failed back syndrome in 6 patients, destructive spondyloarthropathy in 4 patients, and Charcot spine in 3 patients. All patients underwent posterolateral fusion surgery incorporating lumbar, S1 and iliac screws. We evaluated the pain scores, bone union, and degeneration of sacroiliac joints by X-ray imaging and computed tomography before and 3 years after surgery. For evaluation of low back and buttock pain from sacroiliac joints 3 years after surgery, lidocaine was administered in order to examine pain relief thereafter.ResultsPain scores significantly improved after surgery. All patients showed bone union at final follow-up. Degeneration of sacroiliac joints was not seen in the 20 patients 3 years after surgery. Patients showed slight low back and buttock pain 3 years after surgery. However, not all patients showed relief of the low back and buttock pain after injection of lidocaine into the sacroiliac joint, indicating that their pain did not originate from sacroiliac joints.ConclusionThe fusion rate and clinical results were excellent. Also, degeneration and pain from sacroiliac joints were not seen within 3 years after surgery. We recommend sacroiliac fixation using iliac screws for highly unstable lumbar spine.

Sacropelvic Fixation

Case report. To describe a new method of minimally invasive percutaneous sacropelvic fixation and to report on its use in two patients. The Galveston and iliac screw techniques are in widespread use for sacropelvic fixation, but neither technique is amenable to a percutaneous approach. The S2-alar-iliac technique is a recently described method that involves finding a pathway from the S2 sacrum into the ilium with fluoroscopy. We describe a new minimally invasive approach for this technique that allows percutaneous insertion of the screws and spinal construct. A 69-year-old female with follicular thyroid carcinoma metastatic to the sacrum and a 55-year-old male with a sacral fracture were both treated with the new technique. We have described this new technique and reviewed the patients' clinical history, radiographic imaging, and outcomes. Stable fixation was achieved in both cases. Blood loss was 70 and 45 mL, respectively. There were no intraoperative complications. To our knowledge, this report is the first description of a percutaneous minimally invasive approach to sacropelvic fixation in spinal fusion surgery. It is likely that this minimally invasive technique will result in less blood loss, lower infection rates, and a more rapid postoperative recovery than that associated with the more widely used open techniques.

Sacropelvic Fixation

Literature-based topic review. To review the indications and techniques for different sacropelvic fixation methods and to outline important associated complications. Despite all the advances and new developments in spinal instrumentation techniques, fixation at the lumbosacral junction continues to be one of the important challenges to spine surgeons. The poor bone quality of the sacrum, the complex regional anatomy, and the tremendous biomechanical forces at the lumbosacral junction contribute to the high rates of instrumentation-related problems. Although many techniques for sacropelvic fixation have been attempted, only a few are still widely used because of the high rate of complications associated with some of those techniques. Review of literature and expert opinion. There are many indications for sacropelvic fixation. Long fusions to the sacrum are the most common reasons for extending the instrumentation to the pelvis. Spinal surgeons performing complex spinal reconstruction should be familiar with the currently available techniques, including their potential risks and complications. Surgical treatment decisions should be based on an individual patient's anatomy and abnormalities, and on the surgeon's experience.

Surgical management of spinal deformities in cerebral palsy

Cerebral palsy (CP) spinal deformities encompass a spectrum of deformities that are often initially treated nonoperatively, only to result in progression of scoliotic curves and further morbidity. Various surgical interventions have been devised to address the progressive curvature of the spine. This endeavor cannot be taken lightly and at times can be encumbered by prior treatments such as the use of baclofen pumps or dorsal rhizotomies. Care of these patients requires a multidisciplinary approach and comprehensive preoperative and postoperative management, including nutritional status, orthopedic assessment of functional level with specific emphasis on the hips and pelvic obliquity, and wheelchair modifications. The surgical techniques in CP scoliosis have progressively evolved from the classic Luque-Galveston fixation methods, the use of unit rods, and lately the use of pedicle screws, to modern sacropelvic fixation. With the latter method, the spinal deformity in patients with CP can usually be almost completely corrected.

Kyphectomy Improves Sitting and Skin Problems in Patients with Myelomeningocele

Progressive kyphosis occurs in up to 20% of patients with myelomeningocele. Severely affected patients can develop recurrent skin breakdown, osteomyelitis, sitting imbalance, and poor cosmetic appearance. We (1) assessed the ability of kyphectomy to restore an intact skin envelope and allow comfortable seating in a wheelchair; (2) reviewed the complications of kyphectomy and spinal fusion in myelomeningocele; and (3) determined whether patients requiring unexpected reoperation had worse correction or more ulceration compared with those patients treated with a single surgery. We retrospectively reviewed the records of 23 children with thoracic-level myelomeningocele who were treated with kyphectomy and spinal fusion since 1980. Indications for surgery included recurrent skin breakdown (15 patients) and poor sitting balance or unacceptable cosmetic deformity (three patients). We evaluated operative technique, type of sacropelvic fixation, surgical complications, radiographic correction, and skin condition at followup. The minimum followup was 2 years (median, 4.1 years; range, 2.1-10 years); 18 of the 23 children had greater than 2 years followup and are reported here. Kyphectomy achieved a sitting balance and resolved in skin ulceration in 17 of 18 patients. Seven patients had complications requiring reoperation. Three patients had multiple reoperations for early deep infection and one patient each had reoperation for late infection, pseudarthrosis, implant-related sacral pressure sore, and planned extension of proximal fusion after growth. Patients requiring multiple operations had similar correction and relief of ulceration to those treated with a single procedure. Complications after kyphectomy are frequent and many children with myelomeningocele and severe hyperkyphosis require multiple procedures and lengthy hospital stays. Nonetheless, improved seating balance and resolution of skin problems was achieved in 17 of 18 patients.