Useful and innovative methods for the treatment of postoperative coronal malalignment in adult scoliosis: the “kickstand rod” and “tie rod” procedures

  • Andrea Redaelli
  • Francesco Langella
  • Michal Dziubak
  • Riccardo Cecchinato
  • Marco Damilano
  • Giuseppe Peretti
  • Pedro BerjanoEmail author
  • Claudio Lamartina
Original Article


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.


Adult spinal deformity Adult scoliosis Complication Coronal imbalance Coronal malalignment Surgical technique 



We thank Alvin Pun, M.D. (Austin Health, Melbourne, Australia), for his assistance in language correction of the manuscript.



Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

586_2019_6285_MOESM1_ESM.pptx (7 mb)
Supplementary material 1 (PPTX 7131 kb)


  1. 1.
    Schwab FJ, Patel A, Ungar B et al (2010) Adult spinal deformity—postoperative standing imbalance assessing alignment and planning corrective surgery. Spine (Phila Pa 1976) 35:2224–2231. CrossRefGoogle Scholar
  2. 2.
    Berjano P, Langella F, Ismael M-F et al (2014) Successful correction of sagittal imbalance can be calculated on the basis of pelvic incidence and age. Eur Spine J 23(Suppl 6):587–596. CrossRefPubMedGoogle Scholar
  3. 3.
    Ploumis A, Simpson A, Cha TD et al (2015) Coronal spinal balance in adult spine deformity patients with long spinal fusions: a minimum 2- to 5-year follow-up study. J Spinal Disord Tech 28:341–347CrossRefGoogle Scholar
  4. 4.
    Berjano P, Lamartina C (2014) Classification of degenerative segment disease in adults with deformity of the lumbar or thoracolumbar spine. Eur Spine J 23:1815–1824. CrossRefPubMedGoogle Scholar
  5. 5.
    Cecchinato R, Berjano P, Aguirre MF, Lamartina C (2015) Asymmetrical pedicle subtraction osteotomy in the lumbar spine in combined coronal and sagittal imbalance. Eur Spine J 24(Suppl 1):S66–S71. CrossRefPubMedGoogle Scholar
  6. 6.
    Bao H, Yan P, Qiu Y et al (2016) Coronal imbalance in degenerative lumbar scoliosis: prevalence and influence on surgical decision-making for spinal osteotomy. Bone Jt J. CrossRefGoogle Scholar
  7. 7.
    Obeid I, Bourghli A, Boissière L et al (2014) Complex osteotomies vertebral column resection and decancellation. Eur J Orthop Surg Traumatol. CrossRefPubMedGoogle Scholar
  8. 8.
    Glassman SD, Berven S, Bridwell K et al (2005) Correlation of radiographic parameters and clinical symptoms in adult scoliosis. Spine (Phila Pa 1976) 30:682–688CrossRefGoogle Scholar
  9. 9.
    Mac-Thiong J-M, Transfeldt EE, Mehbod AA et al (2009) Can c7 plumbline and gravity line predict health related quality of life in adult scoliosis? Spine (Phila Pa 1976) 34:E519–E527. CrossRefGoogle Scholar
  10. 10.
    Koller H, Pfanz C, Meier O, Hitzl W, Mayer M, Bullmann V, Schulte TL (2016) Factors influencing radiographic and clinical outcomes in adult scoliosis surgery: a study of 448 European patients. Eur Spine J 25:532–548. CrossRefPubMedGoogle Scholar
  11. 11.
    Obeid I, Berjano P, Lamartina C et al (2019) Classification of coronal imbalance in adult scoliosis and spine deformity: a treatment-oriented guideline. Eur Spine J 28:94–113. CrossRefPubMedGoogle Scholar
  12. 12.
    Ye X, Lou D, Ding X et al (2017) A clinical study of the coronal plane deformity in Parkinson disease. Eur spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 26:1862–1870. CrossRefGoogle Scholar
  13. 13.
    Barone P, Santangelo G, Amboni M et al (2016) Pisa syndrome in Parkinson’s disease and parkinsonism: clinical features, pathophysiology, and treatment. Lancet Neurol 15:1063–1074. CrossRefPubMedGoogle Scholar
  14. 14.
    Obeid I, Boissière L, Vital J-M, Bourghli A (2014) Osteotomy of the spine for multifocal deformities. Eur Spine J 24:83–92. CrossRefGoogle Scholar
  15. 15.
    Takahashi T, Hanakita J, Watanabe M et al (2014) Lumbar alignment and clinical outcome after single level asymmetrical transforaminal lumbar interbody fusion for degenerative spondylolisthesis with local coronal imbalance. Neurol Med Chir (Tokyo) 54:691–697. CrossRefGoogle Scholar
  16. 16.
    Berjano P, Lamartina C (2013) Far lateral approaches (XLIF) in adult scoliosis. Eur Spine J 22:242–253. CrossRefGoogle Scholar
  17. 17.
    Bianco K, Norton R, Schwab F et al (2014) Complications and intercenter variability of three-column osteotomies for spinal deformity surgery: a retrospective review of 423 patients. Neurosurg Focus 36:E18. CrossRefPubMedGoogle Scholar
  18. 18.
    Makhni MC, Meghan Cerpa, Lin JD, Park PJ, Lenke LG (2018) The “Kickstand Rod” technique for correction of coronal imbalance in patients with adult spinal deformity: theory and technical considerations. J Spine Surg 4(4):798–802. CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Langella F, Villafañe JH, Damilano M et al (2017) Predictive accuracy of Surgimap surgical planning for sagittal imbalance: a cohort study. Spine (Phila Pa 1976) 42:E1297–E1304. CrossRefGoogle Scholar
  20. 20.
    Berjano P, Ismael MF, Damilano M et al (2014) Successful correction of sagittal imbalance can be calculated on the basis of pelvic incidence and age. Eur Spine J 23:S587–S596. CrossRefGoogle Scholar
  21. 21.
    Berjano P, Cecchinato R, Damilano M et al (2013) Preoperative calculation of the necessary correction in sagittal imbalance surgery: validation of three predictive methods. Eur Spine J. CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Pérez-Grueso FS, Cecchinato R, Berjano P (2014) Ponte osteotomies in thoracic deformities. Eur Spine J. CrossRefPubMedGoogle Scholar
  23. 23.
    Berjano P, Pejrona M, Damilano M et al (2014) Corner osteotomy: a modified pedicle subtraction osteotomy for increased sagittal correction in the lumbar spine. Eur Spine J. CrossRefPubMedGoogle Scholar
  24. 24.
    Harrington P (1962) Treatment of scoliosis. Correction and internal fixation by spine instrumentation. J Bone Joint Surg Am 44-A:591–610CrossRefGoogle Scholar
  25. 25.
    Allen BL, Ferguson RL (1984) The Galveston technique of pelvic fixation with L-rod instrumentation of the spine. Spine (Phila Pa 1976) 9(4):388–394. CrossRefGoogle Scholar
  26. 26.
    Hyun S-J, Lenke LG, Kim Y-C et al (2014) Comparison of standard 2-rod constructs to multiple-rod constructs for fixation across 3-column spinal osteotomies. Spine (Phila Pa 1976) 39:1899–1904. CrossRefGoogle Scholar
  27. 27.
    Bao H, Liu Z, Zhang Y, Sun X, Jiang J, Qian B, Mao S, Qiu Y, Zhu Z (2019) Sequential correction technique to avoid postoperative global coronal decompensation in rigid adult spinal deformity: a technical note and preliminary results. Eur Spine J. CrossRefPubMedGoogle Scholar
  28. 28.
    Aebi M (2005) The adult scoliosis. Eur Spine J 14(10):925–948. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Authors and Affiliations

  1. 1.IRCCS Istituto Ortopedico GaleazziMilanItaly
  2. 2.Department of Biomedical Sciences for HealthUniversity of MilanMilanItaly

Personalised recommendations