The impact of preoperative supine radiographs on surgical strategy in adult spinal deformity

OBJECTIVE Preoperative planning for adult spinal deformity (ASD) surgery is essential to prepare the surgical team and consistently obtain postoperative alignment goals. Positional imaging may allow the surgeon to evaluate spinal flexibility and anticipate the need for more invasive techniques. The purpose of this study was to determine whether spine flexibility, defined by the change in alignment between supine and standing imaging, is associated with the need for an osteotomy in ASD surgery. METHODS A single-center, dual-surgeon retrospective analysis was performed of adult patients with ASD who underwent correction of a thoracolumbar deformity between 2014 and 2018 (pelvis to upper instrumented vertebra between L1 and T9). Patients were stratified into osteotomy (Ost) and no-osteotomy (NOst) cohorts according to whether an osteotomy was performed (Schwab grade 2 or higher). Demographic, surgical, and radiographic parameters were compared. The sagittal correction from intraoperative prone positioning alone (sagittal flexibility percentage [Sflex%]) was assessed by comparing the change in lumbar lordosis (LL) between preoperative supine to standing radiographs and preoperative to postoperative alignment. RESULTS Demographics and preoperative and postoperative sagittal alignment were similar between the Ost (n = 60, 65.9%) and NOst (n = 31, 34.1%) cohorts (p > 0.05). Of all Ost patients, 71.7% had a grade 2 osteotomy (mean 3 per patient), 21.7% had a grade 3 osteotomy, and 12.5% underwent both grade 3 and grade 2 osteotomies. Postoperatively, the NOst and Ost cohorts had similar pelvic incidence minus lumbar lordosis (PI-LL) mismatch (mean PI-LL 5.2° vs 1.2°; p = 0.205). Correction obtained through positioning (Sflex%) was significantly lower for in the osteotomy cohort (38.0% vs 76.3%, p = 0.004). A threshold of Sflex% < 70% predicted the need for osteotomy at a sensitivity of 78%, specificity of 56%, and positive predictive value of 77%. CONCLUSIONS The flexibility of the spine is quantitatively related to the use of an osteotomy. Prospective studies are needed to determine thresholds that may be used to standardize surgical decision-making in ASD surgery.