Role of T2 pedicle subtraction osteotomy in rigid cervicothoracic sagittal imbalance correction: A case series with technical details

Background: Correction of rigid cervicothoracic sagittal imbalance is technically demanding, especially in patients with prior cervical fusion or ankylosing spondylitis. Three-column osteotomies at C6–T1 can achieve deformity correction but carry risks of vertebral artery and cervical nerve root injury. T2 pedicle subtraction osteotomy (PSO) may provide comparable correction with a more favorable neurovascular risk profile. We evaluated radiographic outcomes, durability of correction, and safety of T2 PSO for rigid cervicothoracic deformity. Materials and Methods: Nineteen consecutive patients who underwent T2 PSO (2017–2025) were retrospectively reviewed. Radiographic parameters, including C2–C7 sagittal vertical axis (SVA), C2–S1 SVA, T1 slope (TS), TS–CL mismatch, and C6–T4 cervicothoracic angle (CTA), were assessed preoperatively, immediately postoperatively, and at last follow-up. Complications and reoperations were recorded. Results: Mean C2–C7 SVA improved from 65.5 mm to 40.1 mm postoperatively (−25.4 mm, P < 0.001) and remained improved at 46.5 mm at final follow-up (P = 0.005). C2–S1 SVA decreased by 30.8 mm (P = 0.008). TS improved from 47.3° to 31.2° (−16.1°, P < 0.001), TS–CL mismatch by 12.9° (P < 0.001), and CTA from 16.7° to 5.2° (−11.5°, P = 0.002). Radiographic gains were largely maintained at a mean 11.6-month follow-up. Complications occurred in 47.4%; one transient neurologic deficit occurred, with no permanent spinal cord, nerve root, or vascular injuries. Conclusion: T2 PSO provides substantial and durable correction of cervicothoracic sagittal imbalance with a favorable neurovascular safety profile, particularly in patients with prior cervical fusion or ankylosing spondylitis.