Andrea Redaelli, Francesco Langella, Michal Dziubak, Riccardo Cecchinato, Marco Damilano, Giuseppe Peretti, Pedro Berjano, Claudio Lamartina

April 2020, Volume 29, Issue 4, pp 849 - 859 Original Article Read Full Article 10.1007/s00586-019-06285-7

First Online: 06 January 2020

Study design

Surgical technique description and case series.


To describe the use of two techniques for the correction of postoperative coronal imbalance after surgical treatment for adult spine deformity (ASD).

Summary of background data

Sagittal and coronal spinal malalignments are often present in patients with ASD or in patients who have undergone spine surgery. Surgical correction of coronal imbalance is insufficiently investigated, and the literature provides a limited spectrum of surgical options when compared to sagittal imbalance. Nevertheless, this deformity can compromise the surgical outcome and can increase the risk of hardware failure.


The kickstand (KR) and tie rod (TR) techniques utilize an accessory rod, linking the previous instrumentation to an independent iliac screw. After a proper release of the lumbar spine with anterior release or posterior osteotomies, the KR technique pushes with distraction on the concave side, whereas the TR technique pulls with compression on the convex side. Four patients (mean age, 64 years; SD 5.7) affected by severe postoperative coronal imbalance were treated. C7-PL ranges from 39 to 76 mm. The mean preoperative ODI was 70/100 (range from 55 to 82). All patients had previous spinopelvic fixation as a consequence of corrective surgery for adult spine deformity. The patients were surgically treated with the addition of supplementary rods connected to the ilium. The rods were used in the concavity or convexity of the deformity functioning as “kickstand” or “tie” or a combination of both.


The mean surgical correction of C7-PL was 35 mm (range from 20 to 52 mm). In particular, the mean correction for kickstand rod technique was 26 mm and for tie rod technique was 43 mm. All of the patients improved their preoperative disability, and mean ODI was 30/100 (range from 10 to 60) at median 19-month follow-up. All postoperative imaging showed implants were in proper position without hardware failure. All of the patients treated demonstrated an immediate postoperative improvement in terms of coronal displacement of the spine. No complications were observed. At 1-year follow-up, all of the patients remained satisfactory in terms of clinical outcomes.


The kickstand and tie rod techniques are effective in the treatment of postoperative coronal malalignment. Further studies are needed to confirm these findings.

Level of evidence

V: Case report.

Graphic abstract

These slides can be retrieved under Electronic Supplementary Material.[graphic not available: see fulltext]

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