Surgery for spinal deformity is complex and often requires performing spinal osteotomies both in pediatric and in adult populations. While surgery for spinal deformity has shown to be associated with improved clinical outcomes and health-related quality of life (HRQOL),^1,2 complication rates following such procedures are not trivial.^3-5 Three column osteotomies often required for rigid spinal deformities and focal angular kyphoscoliosis can be associated with a significantly higher risk of complications, including neurological deficits in both adults and pediatric age groups. Schwab et al⁶ proposed an osteotomy classification system, ranging from grade 1 to grade 6, each with progressive degrees of potential destabilization and bone/soft tissue removal with grade 3 to 6 consisting of various 3-column osteotomies. Grade 6 osteotomy involves a resection of at least 1 complete vertebral body and a partial or complete resection of an adjacent vertebra and is most often described in the literature for the correction of severe sagittal and coronal deformities and is the most aggressive variant of 3-column osteotomy. There are robust data showing that 3-column osteotomy can be associated with significant complication rates, including up to a 10% rate of new onset neurological deficits.⁴ Of all the 3-column osteotomies, Schwab grade 5 osteotomy, commonly termed vertebral column resection (VCR), and Schwab grade 6 osteotomy, where a resection of more than 1/multiple vertebral bodies is performed, are the ones associated with the highest risk of complications, especially neurological deficits. In fact, the resection of more than 1 vertebral body significantly increases the risk of incurring new neurological deficits and should be reserved for cases that cannot be addressed by single-level VCR (Schwab grade 5 osteotomy). Considering the ceiling in the degree of correction that can be obtained with grade 5 osteotomy or single VCR, severe kyphoscoliotic curves with more than 90° kyphosis/scoliosis or more may necessitate performing grade 6 osteotomies.⁴ However, there is an absence of data specifically addressing the indications, safety, and complication profile with Schwab grade 6 osteotomy or resection of more than 1 vertebral body with the majority of the studies combining all 3 column osteotomies and single versus multiple vertebral bodies’ resection together, which may not truly reflect the outcomes following Schwab grade 6 osteotomy.

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评论：脊柱侧弯研究学会Schwab对严重的先天性角膜后凸的6级截骨术：分析17例，最少随访2年。

脊柱畸形的手术很复杂，在儿童和成人人群中通常都需要进行脊柱截骨术。虽然脊柱畸形手术已被证明与改善临床结果和健康相关的生活质量（HRQOL）有关，但这种手术后的^1,2并发症发生率并非微不足道。^3-5刚性脊柱畸形和局灶性角后凸性脊柱侧凸经常需要进行三柱截骨术，这可能会大大增加并发症的风险，包括成人和儿童年龄组的神经功能缺损。施瓦布等⁶提出了一种截骨术分类系统，范围从1级到6级，每个系统具有潜在的不稳定程度和逐渐去除骨/软组织的程度，而3级到6级则由各种3列截骨术组成。6级截骨术包括切除至少1个完整的椎体和切除相邻椎骨的部分或全部，并且在文献中最常被描述用于矫正严重的矢状和冠状畸形，并且是3柱中最具攻击性的一种截骨术。有可靠的数据表明，三柱截骨术可与明显的并发症发生率相关，包括高达10％的新发神经功能缺损率。⁴在所有三柱截骨术中，施瓦布5级截骨术（通常称为椎弓根切除术（VCR））和施瓦布6级截骨术（其中切除术多于1个/多个椎体）是发生风险最高的方法。并发症，尤其是神经系统缺陷。实际上，切除一个以上的椎体会明显增加发生新的神经功能缺损的风险，因此应保留用于单级VCR（Schwab 5级截骨术）无法解决的病例。考虑到5级截骨术或单VCR可获得的矫正度上限，严重的后凸脊柱侧弯弯曲度超过90°后凸/脊柱侧弯或更高，可能需要进行6级截骨。⁴ 但是，目前尚无专门针对Schwab 6级截骨术或多于1个椎体切除术的适应症，安全性和并发症情况进行研究的数据，而大多数研究都结合了所有3栏截骨术和单或多椎体切除术可能无法真正反映Schwab 6级截骨术后的结局。