Key Role of Preoperative Recumbent Films in the Treatment of Severe Sagittal Malalignment

Abstract Study Design Retrospective cohort study. Objective To determine if severe sagittal malalignment (SM) patients without fixed deformities require a three-column osteotomy (3CO) to achieve favorable clinical and radiographic outcomes. Summary of Background Data 3CO performed for severe SM has significantly increased in the last 15 years. Not all severe SM patients require a 3CO. Methods Severe SM patients (sagittal vertical axis [SVA] >10 cm) who underwent deformity correction between 2002 and 2011. Patients with Results Seventy patients met the inclusion criteria, 35 patients with flexible and 35 with stiff deformities. Eighteen flexible-deformity patients underwent a 3CO versus 22 stiff-deformity patients. The remaining patients in each group underwent spinal realignment without a 3CO. The flexible-deformity patients not undergoing a 3CO had overall improvement in all sagittal radiographic parameters. Preoperative LL (22°), LL–pelvic incidence (PI) mismatch (43), SVA (17 cm), and pelvic tilt (PT, 34°) improved to 46°, 18, 6 cm, and 26°, respectively, p  Conclusion Severe SM that is flexible can be corrected without a 3CO without compromising clinical and radiographic outcomes. Level of Evidence Level III.