Anterior Release + PSF

When a kyphosis is very large, very stiff, or has partly stiffened into a bridge of bone, correcting it from the back alone can be difficult, because the front of the spine is locked and will not allow the curve to straighten. The rationale for the combined approach is to address the deformity from both sides: first release the tight front of the spine — dividing the anterior ligament and removing the apical discs — to create flexibility, then use posterior instrumentation to correct the curve and fuse it solidly. Historically this combined approach was the standard for severe Scheuermann's and other rigid kyphoses, and the anterior column support it provides was thought to reduce the chance of the correction failing at the junctions. Today it is reserved for the most rigid or severe deformities, because modern posterior-only techniques handle most curves without an anterior operation.

This is what is generally done, although techniques vary between surgeons and centres, and the two stages may be performed in one sitting or on separate days. In the anterior stage, the front of the spine is reached at the apex — through an open chest incision or, increasingly, using keyhole thoracoscopic techniques — and the anterior longitudinal ligament and several apical discs are removed, releasing the tether and mobilising the spine; bone graft may be placed in the emptied disc spaces. In the posterior stage, the spine is exposed through the back, pedicle screws are placed on both sides, and the now-flexible curve is corrected using contoured rods, often with additional posterior osteotomies, and fused with bone graft into one solid, aligned column. The nerves are monitored throughout, and the lungs, blood loss and general health are managed carefully because two approaches are involved.

Large series of the combined anterior-and-posterior approach report durable, substantial correction of severe kyphosis — commonly around 47 to 53 percent — with the anterior column support historically thought to protect against junctional failure. However, comparative and meta-analytic literature consistently shows that, compared with a posterior-only pedicle-screw fusion, the combined approach involves longer operating time, greater blood loss, and a higher overall complication rate — including junctional kyphosis above or below the fusion, and higher revision rates — while achieving broadly comparable long-term correction and quality-of-life outcomes. For this reason the combined operation is now generally reserved for the most rigid, severe or partly-fused deformities that cannot be adequately mobilised from the back, and the clear trend in the evidence is towards posterior-only correction for the majority of kyphoses. When the combined approach is used, it can be staged over two days or performed in a single sitting, depending on the case.

Because two approaches are involved, recovery is generally a little longer than after a posterior-only operation, and the team supports patients throughout. Where the chest has been entered, a temporary drain is used for a short time and breathing is supported and monitored closely early on. Pain is managed actively, and getting up and moving is encouraged as soon as it is safe. A hospital stay of several days to over a week is common. Over the following months the fusion becomes solid, strenuous activity and contact sport are limited during that time, and a graded return to normal life is guided by the team. Many people stand noticeably taller and straighter once the curve is corrected. The spine is then followed up over the long term to confirm the correction holds and that no junctional bend has developed.

This is major surgery through two approaches, and it carries risks the team discusses fully beforehand. In addition to the general risks of spinal surgery — bleeding, infection, and a small risk of nerve injury (the nerves are monitored during the operation) — reaching the front of the spine through the chest adds effects on the lungs and breathing and the risks of chest surgery. Because the combined approach carries a higher complication burden and longer recovery than posterior-only surgery while achieving similar long-term correction in most cases, it is reserved for deformities that genuinely require it. This page is educational and does not recommend or advise for or against surgery, or any particular approach, in any individual case.

• —Bradford DS et al. Combined anterior and posterior fusion for Scheuermann's kyphosis. (PMID 7280811)
• —Comparison of Scheuermann's kyphosis correction by combined anterior-posterior fusion versus posterior-only procedure. (PMID 26365711)
• —Lonner BS et al. Comparison of Scheuermann kyphosis correction by posterior-only fixation versus combined anterior/posterior fusion. (PMID 16985459)
• —Surgical treatment of Scheuermann's kyphosis using a combined antero-posterior strategy and pedicle screw constructs: 111 cases. (PMC3897835)
• —Two-stage anterior and posterior fusion versus one-stage posterior fusion in Scheuermann's kyphosis. (PMID 32993336)
• —Anterior and posterior spinal fusion: comparison of one-stage and two-stage procedures. (PMID 8221405)
• —Posterior-only versus combined anterior/posterior fusion in Scheuermann disease: a large retrospective study. (PMID 29779056)
• —Complications of spinal fusion for Scheuermann kyphosis: report of the SRS Morbidity and Mortality Committee. (PMID 20042960)
• —Surgical procedures used for correction of Scheuermann's kyphosis: a meta-analysis. (PMC8557059)
• —Complications in operative Scheuermann kyphosis: do the pitfalls differ from operative adolescent idiopathic scoliosis? (PMID 25901978)
• —Treatment approaches for Scheuermann kyphosis: a systematic review of historic and current management. (PMID 31675699)
• —Scheuermann's kyphosis: surgical management. (PMID 15830215)
• —Scheuermann's kyphosis: current controversies. (PMID 21705553)
• —Treatment of stiff thoracic scoliosis by thoracoscopic anterior release combined with posterior instrumentation and fusion. (PMID 17937803 / PMC2173894)