Is There a Better Alternative to Three Column Osteotomies? Analysis of Prone Lateral Anterior Column Realignment and Their Outcomes After Minimally Invasive Spine Surgery

Introduction: Anterior column realignment (ACR) is a technique introduced as a less invasive alternative to methods like three-column osteotomies for restoring sagittal alignment. Traditionally performed from a lateral or anterior approach, ACR has not yet been described as a prone-lateral surgical approach.

Methods: Operative MIS fusion patients available up to 2Y data from a single-center database were included. Patients stratified into two groups based on approach: Prone-Lateral ACR (ACR) vs Non-Prone-Lateral ACR (NACR). Descriptive analyses and means comparison tests identified differences in BL demographics, surgical details, radiographic parameters. Multivariate logistic regression used to assess the effect of approach on outcomes and rates of intraoperative and postoperative complications up to 2Y.

Results: 104 included (56.1±11.4y, 30.6±6.6kg/m2, 54%F, CCI: 1.2±1.9). Surgical details: 11.5±4 levels fused, EBL: 1565±1406 mL, op time: 371±136 min, LOS: 8.5±4.6 days. 79 underwent prone-lateral ACR. ACR had comparable age and BMI compared to NACR. However, ACR had significantly lower EBL(313.4ml vs 728mL) and shorter LOS postoperatively(3 days vs 5.1 days, both p<.001). ACR also had significantly less osteotomies(8.1% vs 31%, p<.001) despite similar baseline deformity(all p>.05). ACR also suffered significantly less delayed extubation (12% vs 25%, p=.005) and lower SICU rates (.1% vs 29%, p<.001). ACR had decreased discharge to rehabilitation facility(0% vs. 13%, p<.001). Overall complications rates were significantly lower for ACR(2.3% vs. 7.6%, p=.012), with lower rates of mechanical complications(0% vs 5%, p=.011). However, increased minor vascular injuries were reported(3.2% vs 1.2%, p=.02). ACR had greater improvement in ODI over 2 years(-6.0 vs. -3.3, p=.03). Multivariate analysis found ACR had greater odds of achieving MCID in ODI (OR: 1.692, [1.231, 2.326], p=.001) despite higher NRS Leg Score (OR: 1.163, [1.273, 2.173], p<.001).

Conclusion : Prone-Lateral ACR has several advantages, including avoidance of invasive osteotomies and manipulation of neural structures. These patients displayed less invasive procedures with similar degree of correction, endured less rates of complications correlating to going home earlier and more often. Thus, prone lateral anterior column realignment approach to minimally invasive spine surgery is an effective alternative to the more intensive approach of osteotomies and staged or flipped procedures.