Tag: adult deformity

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Do all patients with adult scoliosis need instrumented fusion from T10 to the pelvis?

J Neurosurg Spine 44:195–204, 2026

This clinical review addresses whether adult scoliosis uniformly requires instrumented fusion from T10 to the pelvis, presenting diagnostic frameworks, radiographic assessment, and surgical decision-making. It contrasts full-length thoracolumbar–pelvic constructs with shorter, focal interventions, emphasizing individualized selection based on pain generators, balance, deformity location, and comorbidities.

The article reviews indications for extending fusions to upper thoracic levels, risks such as proximal junctional kyphosis, and evidence supporting limited fusion or decompression-only strategies when focal pathology (fractional curve, foraminal stenosis, olisthesis) explains symptoms. Multiple case examples illustrate practical application of the decision algorithm and outcomes.

Individualized Treatment: Not all adult scoliosis patients require instrumented fusion from T10 to the pelvis; surgical decisions should be based on the patient’s symptoms, pain generator, spinal balance, and radiographic findings rather than a one-size-fits-all approach.

Pain Source Identification: Careful identification of the pain generator (scoliosis-related, neurogenic, facet, or sacroiliac) is critical; many patients have back pain unrelated to scoliosis and may benefit from focal or limited procedures instead of extensive fusion.

Fusion Level Selection: The choice of upper instrumented vertebra (UIV) depends on curve characteristics, presence of kyphosis, risk of proximal junctional kyphosis (PJK), and patient-specific factors; fusion may end at T10, upper thoracic, or even lumbar levels as appropriate.

Limited/Focal Surgery: In select cases, limited fusion (e.g., of the major curve, concavity, or fractional curve) or even decompression alone can be effective, especially for patients with focal symptoms or significant comorbidities who cannot tolerate extensive surgery.

Fractional Curve Fusion: Fusion of only the fractional curve (typically L4–S1) is effective for radicular pain referable to this segment; careful preoperative assessment of coronal alignment and curve type is necessary to avoid postoperative imbalance.

Radiographic-Clinical Correlation: Surgical planning should integrate both radiographic parameters (sagittal vertical axis, pelvic incidence–lumbar lordosis mismatch, coronal balance) and the patient’s clinical presentation, as discordance may require further investigation.

Risks of Extensive Fusion: Long-segment fusions (T10–pelvis or longer) carry significant morbidity and complication risks; such approaches are best reserved for cases with severe, disabling symptoms, progressive deformity, or global imbalance.

Patient Preferences and Expectations: Surgical decisions must consider patient quality of life, goals, psychological profile, and willingness to accept surgical risks or possible reoperation, with shared decision-making emphasized

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Correction of severe spinopelvic mismatch: decreased blood loss with lateral hyperlordotic interbody grafts as compared with pedicle subtraction osteotomy

Neurosurg Focus 43 (2):E15, 2017

Pedicle subtraction osteotomy (PSO) provides extensive correction in patients with fixed sagittal plane imbalance but is associated with high estimated blood loss (EBL). Anterior column realignment (ACR) with lateral graft placement and sectioning of the anterior longitudinal ligament allows restoration of lumbar lordosis (LL). The authors compare peri- and postoperative measures in 2 groups of patients undergoing correction of a sagittal plane imbalance, either through PSO or the use of lateral lumbar fusion and ACR with hyperlordotic (20°–30°) interbody cages, with stabilization through standard posterior instrumentation in all cases.

METHODS The authors performed a retrospective chart review of cases involving a lumbar PSO or lateral lumbar interbody fusion and ACR (LLIF-ACR) between 2010 and 2015 at the authors’ institution. Patients who had a PSO in the setting of a preexisting fusion that spanned more than 4 levels were excluded. Demographic characteristics, spinopelvic parameters, EBL, operative time, and LOS were analyzed and compared between patients treated with PSO and those treated with LLIF-ACR.

RESULTS The PSO group included 14 patients and the LLIF-ACR group included 13 patients. The mean follow-up was 13 months in the LLIF-ACR group and 26 months in the PSO group. The mean EBL was significantly lower in the LLIF-ACR group, measuring approximately 50% of the mean EBL in the PSO group (1466 vs 2910 ml, p < 0.01). Total LL correction was equivalent between the 2 groups (35° in the PSO group, 31° in the LLIF-ACR group, p > 0.05), as was the preoperative PI-LL mismatch (33° in each group, p > 0.05) and the postoperative PI-LL mismatch (< 1° in each group, p = 0.05). The fusion rate as assessed by the need for reoperation due to pseudarthrosis was lower in the LLIF-ACR group but not significantly so (3 revisions in the PSO group due to pseudarthrosis vs 0 in the LLIF-ACR group, p > 0.5). The total operative time and LOS were not significantly different in the 2 groups.

CONCLUSIONS This is the first direct comparison of the LLIF-ACR technique with the PSO in adult spinal deformity correction. The study demonstrates that the LLIF-ACR provides equivalent deformity correction with significantly reduced blood loss in patients with a previously unfused spine compared with the PSO. This technique provides a powerful means to avoid PSO in selected patients who require spinal deformity correction.

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Pelvic retroversion: a compensatory mechanism for lumbar stenosis

J Neurosurg Spine 27:137–144, 2017

The flexed posture of the proximal (L1–3) or distal (L4–S1) lumbar spine increases the diameter of the spinal canal and neuroforamina and can relieve symptoms of neurogenic claudication. Distal lumbar flexion can result in pelvic retroversion; therefore, in cases of flexible sagittal imbalance, pelvic retroversion may be compensatory for lumbar stenosis and not solely compensatory for the sagittal imbalance as previously thought. The authors investigate underlying causes for pelvic retroversion in patients with flexible sagittal imbalance.

METHODS One hundred thirty-eight patients with sagittal imbalance who underwent a total of 148 fusion procedures of the thoracolumbar spine were identified from a prospective clinical database. Radiographic parameters were obtained from images preoperatively, intraoperatively, and at 6-month and 2-year follow-up. A cohort of 24 patients with flexible sagittal imbalance was identified and individually matched with a control cohort of 23 patients with fixed deformities. Flexible deformities were defined as a 10° change in lumbar lordosis between weight-bearing and non–weight-bearing images. Pelvic retroversion was quantified as the ratio of pelvic tilt (PT) to pelvic incidence (PI).

RESULTS The average difference between lumbar lordosis on supine MR images and standing radiographs was 15° in the flexible cohort. Sixty-eight percent of the patients in the flexible cohort were diagnosed preoperatively with lumbar stenosis compared with only 22% in the fixed sagittal imbalance cohort (p = 0.0032). There was no difference between the flexible and fixed cohorts with regard to C-2 sagittal vertical axis (SVA) (p = 0.95) or C-7 SVA (p = 0.43). When assessing for postural compensation by pelvic retroversion in the stenotic patients and nonstenotic patients, the PT/PI ratio was found to be significantly greater in the patients with stenosis (p = 0.019).

CONCLUSIONS For flexible sagittal imbalance, preoperative attention should be given to the root cause of the sagittal misalignment, which could be compensation for lumbar stenosis. Pelvic retroversion can be compensatory for both the lumbar stenosis as well as for sagittal imbalance.

 

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