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Objective: To analyze ideal indication for combined anterior column realignment (ACR) with short posterior spinal fusion (PSF) and posterior column osteotomy (PCO) for preventing proximal junctional kyphosis (PJK) in adult spinal deformity (ASD) patients with lower lumbar kyphosis and compensatory thoracolumbar lordosis. Methods: A retrospective study was conducted. This study included 27 ASD patients (average age of 66.6 years; one male and 26 females) with lower lumbar kyphosis and compensated thoracolumbar lordosis who underwent short PSF with PCO following ACR from 2006 to 2010. The minimum follow‐up period was 5 years. The patients were divided into two groups based on the sagittal vertical axis (SVA) of the last follow‐up radiographs, and a comparative analysis was performed evaluating spino‐pelvic parameters and clinical outcomes including the Oswestry Disability Index (ODI), Visual Analog Scale (VAS), and complications. Results: The mean follow‐up time of included patients was 109.7 months, and the mean number of fused segments was 3.7. The uppermost instrumented vertebra was L2 in 18 patients or L3 in nine patients, and lowermost instrumented vertebra was sacrum in all patients. The mean lumbar lordosis (LL) values in the optimal SVA and suboptimal SVA groups were 4.4° and 4.2° preoperatively (P = 0.639), −48.1° and −35° postoperatively (P = 0.007), and −45.2° and −20.7° at the last follow‐up (P < 0.05). Overcorrection was seen in seven patients in the optimal SVA group, whereas all of the patients of the suboptimal SVA group were in the category of undercorrection (P = 0.021). Pelvic incidence (PI) of optimal SVA group (<50 mm, n = 16) and suboptimal SVA group (≥50 mm, n = 11) was 44.1° and 53.8° (P = 0.009). The prevalence of PJK was significantly higher in the suboptimal SVA group (P = 0.008), and last follow‐up VAS for back pain (P < 0.05), and postoperative and last follow‐up ODI (P = 0.002 and P < 0.05) were statistically larger for the suboptimal group than the optimal group. Conclusions: Combined ACR with short PSF and PCO could effectively prevent sagittal decompensation of PJK and help achieve sagittal balance in the treatment of ASD patients with lower lumbar kyphosis, compensatory thoracolumbar lordosis, and especially low PI (<50°). [ABSTRACT FROM AUTHOR]

Background: The anterior-to-psoas (ATP) approach to the lumbar spine has been proposed as an alternative to the transpsoas approach for approaching the disc space without dissecting through the psoas muscle, thus decreasing the risk of injury to the lumbar plexus. There are no prior studies that evaluates the clinical application of anterior longitudinal ligament (ALL) release and anterior column realignment (ACR) using the ATP approach. The objective of this study was to describe and evaluate the safety of ACR using an ATP approach with release of both the ALL and bilateral annulus for correction of a focal kyphotic lumbar deformity., Methods: A retrospective analysis of fourteen consecutive patients at a single institution between January 2017 and December 2019 of patients undergoing ACR using an ATP approach for lumbar flatback syndrome with focal kyphotic lumbar deformity by a single surgeon was performed. Primary outcome measures were pre- and postoperative radiographic parameters. Secondary outcome measures were perioperative adverse events (AEs), 30-day readmissions/reoperations, discharge disposition, post-operative length of stay (LOS), and radiographic complications., Results: Fourteen consecutive patients (mean age 67.0±3.9 years, 8 males, 6 females) with 15 total ACR levels were included in the study. A grade 1 posterior column osteotomy (PCO) with posterior instrumentation was performed at all ACR levels. L2-L3 ACR was performed in nine patients, L3-L4 in four patients, and L4-L5 in two patients. Mean preoperative disk lordotic angle at the ACR level was 5.4°±5.9° of kyphosis. Mean increase in postoperative disk lordotic angle was 24.0°±8.5° at a mean follow-up of 34.0±23.4 months., Conclusions: ACR can be performed with a complete ALL release under direct visualization using the ATP approach. This technique can be a safe and effective method for achieving substantial correction of a focal kyphotic deformity within the lumbar spine., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-23-84/coif). RAWM reports that he is a paid presenter and speaker of DePuy, A Johnson & Johnson Company, and received IP royalties from Globus Medical. The other authors have no conflicts of interest to declare., (2023 Journal of Spine Surgery. All rights reserved.)

Surgical correction of fixed kyphotic deformity or severe sagittal imbalance traditionally involves three column osteotomies, which are associated with high morbidity rates. Anterior column realignment (ACR) has emerged as a minimally invasive alternative for restoring segmental lordosis. This technique involves a lateral approach and release of the anterior longitudinal ligament (ALL), followed by placement of a hyperlordotic interbody cage. In this study, we present a successful case of minimally invasive ACR for the treatment of flatback deformity and adjacent segment disease in a patient with prior L2-S1 fusion. Imaging revealed a flatback deformity, sagittal vertical axis elevation, and spinopelvic disharmony. The patient underwent a multistage procedure involving a lateral retropleural approach for ACR and interbody fusion, followed by open posterior instrumented fusion and vertebroplasties. Postoperatively, the patient experienced significant pain relief and improvement in lumbar lordosis, pelvic tilt, and pelvic incidence-lumbar lordosis mismatch. ACR combined with posterior release allows for manipulation of all three spinal columns, leading to spine reconstruction and improved spinopelvic harmony. We discuss the advantages of ACR, including its minimally invasive nature and potential benefits for patients with sagittal deformities. The presented surgical technique demonstrates the feasibility and efficacy of minimally invasive ACR in addressing flatback deformity and adjacent segment disease., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-23-45/coif). KDT serves as an unpaid editorial board member of Journal of Spine Surgery from December 2022 to November 2024. KDT reports consultant fees from DePuy Synthes, NuVasive, Accelus, Bioventus, and Cerapedics, as well as honoraria from SI-Bone, and is stockholder of NuVasive and Prioprio, outside the submitted work. CS reports consulting fees from NuVasive, Medtronic, SI Bone, and Proprio; royalties from NuVasive, Medtronic and SI Bone; and is stockholder of NuVasive and Prioprio; outside the submitted work. The other authors have no conflicts of interest to declare., (2023 Journal of Spine Surgery. All rights reserved.)

Study Design: The anterior column realignment (ACR) procedure was retrospectively reviewed.Objective: To review surgical technique, complication avoidance, case examples, and published results on ACR.Summary Of Background Data: For surgical correction of sagittal imbalance, three column osteotomies (3CO) have traditionally been employed for large degrees of correction at a single segment. However, 3CO procedures are technically challenging and carry high morbidity rates. ACR was developed as a less invasive procedure for restoring segmental lordosis.Methods: The ACR surgical technique is reviewed. ACR involves either a lateral, trans-psoas or anterior retroperitoneal approach to sectioning the anterior longitudinal ligament/annulus and placing a hyperlordotic cage. ACR usually also involves a second stage posterior column osteotomy. Three case examples are presented. A review of literature on ACR papers was completed.Results: Twelve papers met inclusion criteria. Ten to 27° of segmental lordosis were reported with use of hyperlordotic cages. 19° increase in mean intradiscal angle was reported when ACR was combined with posterior column osteotomy, 13° more than lateral lumbar interbody fusion alone without a hyperlordotic implant. Reported complication rates ranged from 18 to 47%. The most common minor complications were transient hip flexion weakness (9.3%) and transient paresthesia or dysesthesia (12%). There were few reports of major complications, such as bowel perforation (n = 1) or vascular injury (n = 1). Motor deficit was reported in 11 of 75 cases, lower than reported rates for 3CO.Conclusion: ACR is an emerging, less invasive technique for correction of sagittal deformity ACR has similar restorative capacity as other techniques with same or lower complication rates.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

Minimally invasive spinal surgery (MISS) has evolved as a formidable alternative to traditional open techniques to address adult spinal deformity (ASD). As technology advances, an increasingly large body of techniques and implants are available for use in MISS deformity correction. MISS deformity correction includes anterior, lateral, and posterior techniques that can be tailored to each patient while capturing the strength of each respective technique. Previous limitations of obtaining sagittal correction have been overcome with anterior column realignment (ACR) and the mini-open pedicle subtraction osteotomy. This article will describe current techniques and their application for ASD correction., Competing Interests: Conflicts of Interest: Dr. Juan S. Uribe is a consultant for NuVasive, Inc. Misonix and SI-Bone. NuVasive, Inc. provides research support and stock options. The other authors have no conflicts of interest to declare.