Kyphectomy for the treatment of severe kyphosis associated with myelomeningocele was first reported in 1968 by Sharrard . Since then, various techniques for fixation and correction following kyphectomy have been reported. In early reports, short posterior fusions using staples, surgical wires and screws were resulted in significant correction loss in the majority of cases [4, 7, 12]. Thus, long fusions are now preferred after kyphectomy by many surgeons [1, 2, 6, 8]. Kocaoğlu  reported that segmental pedicle screw fixation after kyphectomy was effective for achieving a good sagittal balance. Additionally, some authors have also reported that segmental pedicle screw fixation after kyphectomy is safe and effective for the treatment of kyphotic deformities in patients with achondroplasia providing strong stability [13, 14].
One of the important purposes of the deformity surgery is restoring or maintaining a good sagittal balance. Especially in non-ambulatory patients, sitting without arm supports is crucial. Preoperatively, the patient could sit without any supports, although somewhat unstably. Moreover, the compensatory curves were very rigid, and maximum correction of the kyphosis could result in further sagittal imbalance deteriorating the patient's activities of daily living. Thus, ventral wall of the T12 vertebral body and cranial endplate of the L4 vertebra body were approximated to avoid excessive correction, resulting in the correction of the kyphosis from 154° to 61°, yielding a correction rate of 61%. In previous papers, higher correction rates of from 64% to 86% were reported [1, 2, 5, 6, 8]. Since most previous cases were younger than 20 years of age before skeletal maturity, the development of sagittal imbalance after maximum correction of kyphosis could be avoided because of sufficient flexibility of the upper and lower compensatory curves. On lateral X-ray (Figure 6B), though the trunk inclination was maintained, the inclination of pelvic apparently changed to a more vertical orientation. However, the sitting balance and levels of activities of daily living were maintained after surgery.
The cause of the refractory ulcer in the present case was continuous pressure at the apex of the kyphosis while the patient was sitting in a wheelchair. Additionally, chronic pyogenic spondylitis caused by MRSA at the apex of the kyphosis hinders the ulcer from healing. Although the infection was well controlled by the administration of Vancomycin® prior to surgery, we were afraid of the impending sepsis induced by the residual abscess, and decided that the removal of the infected vertebra by kyphectomy was necessary to prevent the recurrence of infection and ulcer. In the present case, a kyphectomy followed by segmental pedicle screw fixation was selected to prevent the correction loss and recurrence of ulcer.
Although a stable sitting balance was obtained after surgery in the present case, unfortunately an ulcer in the perineal area developed, possibly due to changes in the pressure distribution caused by the realignment of the spinal column. This complication should be considered as possible complication when kyphectomy is indicated in adult patients with myelomeningocele.