Singh, ManjotBalmaceno-Criss, MariahDaher, MohammadLafage, RenaudHamilton, D KojoSmith, Justin SEastlack, Robert KFessler, Richard GGum, Jeffrey LGupta, Munish CHostin, RichardKebaish, Khaled MKlineberg, Eric OLewis, Stephen JLine, Breton GNunley, Pierce DMundis, Gregory MPassias, Peter GProtopsaltis, Themistocles SBuell, ThomasAmes, Christopher PMullin, Jeffrey PSoroceanu, AlexScheer, Justin KLenke, Lawrence GBess, ShayShaffrey, Christopher ISchwab, Frank JLafage, VirginieBurton, Douglas CDiebo, Bassel GDaniels, Alan HInternational Spine Study Group2024-06-192024-06-192024-061878-87501878-8769https://hdl.handle.net/10161/31200<h4>Background context</h4>Severe sagittal plane deformity with loss of L4-S1 lordosis is disabling and can be improved through various surgical techniques. However, data is limited on the differing ability of anterior lumbar interbody fusion (ALIF), pedicle subtraction osteotomy (PSO), and transforaminal lumbar interbody fusion (TLIF) to achieve alignment goals in severely malaligned patients.<h4>Purpose</h4>To examine surgical techniques aimed at restoring L4-S1 lordosis in severe adult spinal deformity (ASD).<h4>Design</h4>Retrospective review of prospectively collected data.<h4>Patient sample</h4>A total of 96 patients who underwent ALIF, PSO, and TLIF were included in this study.<h4>Outcome measures</h4>The following data were observed for all cases: patient demographics, spinopelvic parameters, complications, and PROMs.<h4>Methods</h4>Severe ASD patients with preoperative PI-LL >20°, L4-S1 lordosis <30°, and full body radiographs and patient-reported outcome measures (PROMs) at baseline and six-week postoperative visit were included. Patients were grouped into ALIF (1-2 level ALIF at L4-S1), PSO (L4/L5 PSO), and TLIF (1-2 level TLIF at L4-S1). Comparative analyses were performed on demographics, radiographic spinopelvic parameters, complications, and PROMs.<h4>Results</h4>Among the 96 included patients, 40 underwent ALIF, 27 underwent PSO, and 29 underwent TLIF. At baseline, cohorts had comparable age, sex, race, Edmonton frailty scores and radiographic spinopelvic parameters (p>0.05). However, PSO was performed more often in revision cases (p<0.001). Following surgery, L4-S1 lordosis correction (p=0.001) was comparable among ALIF and PSO patients and caudal lordotic apex migration (p=0.044) was highest among ALIF patients. PSO patients had higher intraoperative estimated blood loss (p<0.001) and motor deficits (p=0.049), and in-hospital ICU admission (p=0.022) and blood products given (p=0.004) but were otherwise comparable in terms of length of stay, blood transfusion given, and postoperative admission to rehab. Likewise, 90-day postoperative complication profiles and six-week PROMs were comparable as well.<h4>Conclusions</h4>ALIF can restore L4-S1 sagittal alignment as powerfully as PSO, with fewer intra-operative and in-hospital complications. When feasible, ALIF is a suitable alternative to PSO and likely superior to TLIF for correcting L4-S1 lordosis among patients with severe sagittal malalignment.International Spine Study GroupJournal article