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: ACR was introduced more recently 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 from a prone-lateral surgical approach.

Methods: Operative MIS patients available up to 2Y data included. Patients stratified into two groups: Prone Lateral ACR (ACR) vs Non-Prone Lateral ACR (NACR). Descriptive analyses and means comparison tests identified differences in baseline demographics, surgical details, radiographic parameters. Multivariate logistic regression assessed effect of approach on outcomes and rates of intraoperative/postoperative complications up to 2 years.

Results: 104 included(56.1±11.4years, 30.6±6.6kg/m2, 54%female, CCI: 1.2±1.9). Surgical characteristics: 11.5±4levels, EBL: 1565±1406mL, op time: 371±136min, LOS: 8.5±4.6days. 79 in ACR cohort. ACR had comparable age and BMI. ACR had significantly lower EBL(313.4ml vs 728mL) and shorter LOS(3 days vs 5.1 days, both p<.001). ACR patients also had significantly less osteotomies (8.1% vs 31%, p<.001) despite similar baseline deformity radiographics (all p>.05). ACR patients also suffered significantly less delayed extubation (12% vs 25%, p=.005) and lower SICU rates (.1% vs 29%, p<.001). This translated into shorter length of stay for ACR patients (3.1 days vs 5.1, p=.01) with decrease discharge to rehabilitation facility (0% vs. 13%, p<.001). Overall complications rates were significantly lower as well (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 patients 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 : This study sought to demonstrate outcomes after PL ACR compared to alternatives. These patients displayed less invasive procedures with similar degree of correction, endured less rates of complications correlating to going home earlier and more often. PL ACR is an effective alternative to the more intensive approach of osteotomies and staged or flipped procedures.