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.

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. These slides can be retrieved under Electronic Supplementary Material.