Plain sitting AP and lateral radiographs of the spine are necessary to document the severity, nature, and location of spinal deformity.

Axial CT of the intended area of fixation, specifically the lumbosacral spine and pelvis, and the thoracic spine in the intended area of thoracic pedicle fixation is essential (Fig. 19.2a, b). If necessary for the specific case, CT of the mid-lumbar spine with or without reconstructions may be helpful (Fig. 19.3).

In patients with myelomeningocele and ventriculoperitoneal (VP) shunts, it is important to know the functional status of the shunt at the time of surgery. Patients who are shunt-dependent and being considered for residual spinal cord resection as part of the indicated spinal release must have a functioning shunt prior to that procedure.

Custom body rings or equivalent

Extra length and diameter wires for large patients

Special wire fixation bolts for larger-diameter wires

Operating table setup as described below

Special bed preparations as described below

Dedicated staff to provide the full-time nursing care necessary during the prolonged hospitalization required to achieve a successful outcome in these extraordinarily challenging cases

We now use a custom ring or similar to fashion circular fixation of the pelvis, which will serve as the foundation to the entire construct (Fig. 19.4).

The upper segment consists of a series of arches to which the thoracic pedicle half-pins are fixed as a block (Fig. 19.5).

The pelvic ring and thoracic pedicle block are attached to each other in a manner required for the specific case: fixed in an acceptable position for patients with mobile-infected pseudarthrosis of the spine and with parallel hinges located under fluoroscopic control and “motors” used in either distraction or compress to effect gradual correction of hyperlordotic or kyphotic deformities (Fig. 19.6).

Any initial indicated procedure (such as anterior and/or posterior spinal release or wound debridement) is carried out in a routine fashion per the surgeon’s preference.

For spinopelvic fixation, we position our patients prone between two operating tables, one to support the thorax and the other to support the legs from the lower pelvic area. The operating tables should be radiolucent to allow fluoroscopic imaging to aid in pedicle half-pin insertion. Split draping of the patient’s upper and lower body segments will then allow circumferential access to the patient’s pelvis and abdomen (Fig. 19.7).

When we use anteriorly placed iliac half-pins to supplement pelvic fixation, we insert them first through anterior exposure of the pelvis (Fig. 19.8) and then turn the patient prone with re-prepping and draping as described above (Fig. 19.9).