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Vedat Deviren, Justin K. Scheer and Christopher P. Ames

Object

Sagittal imbalance of the cervicothoracic spine often causes severe pain and loss of horizontal gaze. Historically, the Smith-Peterson osteotomy has been used to restore sagittal balance. Cervicothoracic junction pedicle subtraction osteotomy (PSO) offers more controlled closure and greater biomechanical stability but has been infrequently reported in the literature. This study details the cervicothoracic PSO technique in 11 cases and correlates clinical kyphosis (chin-brow to vertical angle [CBVA]) with radiographic measurements.

Methods

Between February 2008 and September 2010, 11 patients (mean age 70 years) underwent a modified PSO (10 at C-7, 1 at T-1) for treatment of sagittal imbalance. Preoperative and postoperative sagittal plane radiographic measurements were made. The CBVA was measured on clinical photographs. Operative technique and perioperative correction were reported for all 11 patients and long-term follow-up data was reported for 9 patients, in whom the mean duration of follow-up was 23 months. Outcome measures used for these 9 patients were the Neck Disability Index, the 36-Item Short Form Health Survey (SF-36), and a visual analog scale for neck pain.

Results

The mean values for estimated blood loss, surgical time, and hospital stay in the 11 patients were 1100 ml, 4.3 hours, and 9.9 days, respectively. The mean preoperative and immediate postoperative values (± SD) for cervical sagittal imbalance were 7.9 ± 1.4 cm and 3.4 ± 1.7 cm. The mean overall correction was 4.5 ± 1.5 cm (42.8%), the mean PSO correction 19.0°, and the mean CBVA correction 36.7°. There was essentially no correlation between preoperative C2–T1 radiographic kyphosis and preoperative CBVA (R2 = 0.0165). There was a moderate correlation with PSO correction angle and postoperative CBVA (R2 = 0.38). There was a significant decrease in both the Neck Disability Index (51.1 to 38.6, p = 0.03) and visual analog scale scores for neck pain (8.1 to 3.9, p = 0.0021). The SF-36 physical component summary scores increased by 18.4% (30.2 to 35.8) with no neurological complications.

Conclusions

The cervicothoracic junction PSO is a safe and effective procedure for the management of cervicothoracic kyphotic deformity. It results in excellent correction of cervical kyphosis and CBVA with a controlled closure and improvement in health-related quality-of-life measures even at early time points.

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Jon Park, Justin K. Scheer, T. Jesse Lim, Vedat Deviren and Christopher P. Ames

Object

The Goel technique, in which C1–2 intraarticular spacers are used, may be performed to restore stability to a disrupted atlantoaxial complex in conjunction with the Harms technique of placing polyaxial screws and bilateral rods. However, it has yet to be determined biomechanically whether the addition of the C1–2 joint spacers increases the multiaxial rigidity of the fixation construct. The goal of this study was to quantify changes in multiaxial rigidity of the combined Goel-Harms technique with the addition of C1–2 intraarticular spacers.

Methods

Seven cadaveric cervical spines (occiput–C2) were submitted to nondestructive flexion-extension, lateral bending, and axial rotation tests in a material testing machine spine tester. The authors applied 1.5 Nm at a rate of 0.1 Nm/second and held it constant for 10 seconds. The specimens were loaded 3 times, and data were collected on the third cycle. Testing of the specimens was performed for the following groups: 1) intact (I); 2) with the addition of C-1 lateral mass/C-2 pedicle screws and rod system (I+SR); 3) with C1–2 joint capsule incision, decortication (2 mm on top and bottom of each joint [that is, the C-1 and C-2 surface) and addition of bilateral C1–2 intraarticular spacers at C1–2 junction to the screws and rods (I+SR+C); 4) after removal of the posterior rods and only the bilateral spacers in place (I+C); 5) after removal of spacers and further destabilization with simulated odontoidectomy for a completely destabilized case (D); 6) with addition of posterior rods to the destabilized case (D+SR); and 7) with addition of bilateral C1–2 intraarticular spacers at C1–2 junction to the destabilized case (D+SR+C). The motion of C-1 was measured by a 3D motion tracking system and the motion of C-2 was measured by the rotational sensor of the testing system. The range of motion (ROM) and neutral zone (NZ) across C-1 and C-2 were evaluated.

Results

For the intact spine test groups, the addition of screws/rods (I+SR) and screws/rods/cages (I+SR+C) significantly reduced ROM and NZ compared with the intact spine (I) for flexion-extension and axial rotation (p < 0.05) but not lateral bending (p > 0.05). The 2 groups were not significantly different from each other in any bending mode for ROM and NZ, but in the destabilized condition the addition of screws/rods (D+SR) and screws/rods/cages (D+SR+C) significantly reduced ROM and NZ compared with the destabilized spine (D) in all bending modes (p < 0.05). Furthermore, the addition of the C1–2 intraarticular spacers (D+SR+C) significantly reduced ROM (flexion-extension and axial rotation) and NZ (lateral bending) compared with the screws and rods alone (D+SR).

Conclusions

Study result indicated that both the Goel and Harms techniques alone and with the addition of the C1–2 intraarticular spacers to the Goel-Harms technique are advantageous for stabilizing the atlantoaxial segment. The Goel technique combined with placement of a screw/rod construct appears to result in additional construct rigidity beyond the screw/rod technique and appears to be more useful in very unstable cases.

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Michael M. Safaee, Vedat Deviren, Cecilia Dalle Ore, Justin K. Scheer, Darryl Lau, Joseph A. Osorio, Fred Nicholls and Christopher P. Ames

OBJECTIVE

Proximal junctional kyphosis (PJK) is a well-recognized, yet incompletely defined, complication of adult spinal deformity surgery. There is no standardized definition for PJK, but most studies describe PJK as an increase in the proximal junctional angle (PJA) of greater than 10°–20°. Ligament augmentation is a novel strategy for PJK reduction that provides strength to the upper instrumented vertebra (UIV) and adjacent segments while also reducing junctional stress at those levels.

METHODS

In this study, ligament augmentation was used in a consecutive series of adult spinal deformity patients at a single institution. Patient demographics, including age; sex; indication for surgery; revision surgery; surgical approach; and use of 3-column osteotomies, vertebroplasty, or hook fixation at the UIV, were collected. The PJA was measured preoperatively and at last follow-up using 36-inch radiographs. Data on change in PJA and need for revision surgery were collected. Univariate and multivariate analyses were performed to identify factors associated with change in PJA and proximal junctional failure (PJF), defined as PJK requiring surgical correction.

RESULTS

A total of 200 consecutive patients were included: 100 patients before implementation of ligament augmentation and 100 patients after implementation of this technique. The mean age of the ligament augmentation cohort was 66 years, and 67% of patients were women. Over half of these cases (51%) were revision surgeries, with 38% involving a combined anterior or lateral and posterior approach. The mean change in PJA was 6° in the ligament augmentation group compared with 14° in the control group (p < 0.001). Eighty-four patients had a change in PJA of less than 10°. In a multivariate linear regression model, age (p = 0.016), use of hook fixation at the UIV (p = 0.045), and use of ligament augmentation (p < 0.001) were associated with a change in PJA. In a separate model, only ligament augmentation (OR 0.193, p = 0.012) showed a significant association with PJF.

CONCLUSIONS

Ligament augmentation represents a novel technique for the prevention of PJK and PJF. Compared with a well-matched historical cohort, ligament augmentation is associated with a significant decrease in PJK and PJF. These data support the implementation of ligament augmentation in surgery for adult spinal deformity, particularly in patients with a high risk of developing PJK and PJF.

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Christopher P. Ames, Justin S. Smith, Justin K. Scheer, Shay Bess, S. Samuel Bederman, Vedat Deviren, Virginie Lafage, Frank Schwab and Christopher I. Shaffrey

Sagittal spinal misalignment (SSM) is an established cause of pain and disability. Treating physicians must be familiar with the radiographic findings consistent with SSM. Additionally, the restoration or maintenance of physiological sagittal spinal alignment after reconstructive spinal procedures is imperative to achieve good clinical outcomes. The C-7 plumb line (sagittal vertical axis) has traditionally been used to evaluate sagittal spinal alignment; however, recent data indicate that the measurement of spinopelvic parameters provides a more comprehensive assessment of sagittal spinal alignment. In this review the authors describe the proper analysis of spinopelvic alignment for surgical planning. Online videos supplement the text to better illustrate the key concepts.

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Justin K. Scheer, Jessica A. Tang, Vedat Deviren, Frank Acosta, Jenni M. Buckley, Murat Pekmezci, R. Trigg McClellan and Christopher P. Ames

Object

Ankylosing spondylitis (AS) is a genetic condition that frequently results in spinal sagittal plane deformity of thoracolumbar or cervicothoracic junctions. Generally, a combination of osteotomy and spinal fixation is used to treat severe cases. Although surgical techniques for traumatic injury across the cervicothoracic junction have been well characterized in clinical and biomechanical literature, the specific model of instrumented opening wedge osteotomy in autofused AS has not been studied biomechanically. This study characterizes the structural stability of various posterior fixation techniques across the cervicothoracic junction in spines with AS, specifically considering the effects of posterior rod diameter and material type.

Methods

For each of 10 fresh-frozen human spines (3 male, 7 female; mean age 60 ± 10 years; C3–T6), an opening wedge osteotomy was performed at C7–T1. Lateral mass screws were inserted bilaterally from C-4 to C-6 and pedicle screws from T-1 to T-3. For each specimen, 3.2-mm titanium (Ti), 3.5-mm Ti, and 3.5-mm cobalt chromium (CoCr) posterior spinal fusion rods were tested. To simulate the anterior autofusion and long lever arms characteristic of AS, anterior cervical plates were placed from C-4 to C-7 and T-1 to T-3 using fixed angle screws. Nondestructive flexion-extension, lateral bending, and axial rotation tests were conducted to 3.0 Nm in each anatomical direction; 3D motion tracking was used to monitor primary range of motion across the osteotomy (C7–T1). Biomechanical tests used a repeat-measures test design. The order of testing for each rod type was randomized across specimens.

Results

Constructs instrumented with 3.5-mm Ti and 3.5-mm CoCr rods were significantly stiffer in flexion-extension than those with the 3.2-mm Ti rod (25.2% ± 16.4% and 48.1% ± 15.3% greater than 3.2-mm Ti, respectively, p < 0.05). For axial rotation, the 3.5-mm Ti and 3.5-mm CoCr constructs also exhibited a significant increase in rigidity compared with the 3.2-mm Ti construct (36.1% ± 12.2% and 52.0% ± 20.0%, respectively, p < 0.05). There were no significant differences in rigidity seen between the 3 types of rods in lateral bending (p > 0.05). The 3.5-mm CoCr rod constructs showed significantly higher rigidity in flexion-extension than the 3.5-mm Ti rod constructs (33.1% ± 15.5%, p < 0.05). There was a trend for 3.5-mm CoCr to have greater rigidity in axial rotation (36.2% ± 18.6%), but this difference was not statistically significant (p > 0.05).

Conclusions

The results of this study suggest that 3.5-mm CoCr rods are optimal for achieving the most rigid construct in opening wedge osteotomy in the cervicothoracic region of an AS model. Rod diameter and material properties should be considered in construct strategy. Some surgeons have advocated anterior plating in patients with AS after osteotomy for additional stability and bone graft surface. Although this effect was not examined in this study, additional posterior stability achieved with CoCr may decrease the need for additional anterior procedures.

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Justin K. Scheer, Jessica Tang, Johnny Eguizabal, Azadeh Farin, Jenni M. Buckley, Vedat Deviren, R. Trigg McClellan and Christopher P. Ames

Object

Primary spine tumors frequently involve the C-2 vertebra. Complete resection of the lesion may require total removal of the C-2 vertebral body, pedicles, and dens process. Authors of this biomechanical study are the first to evaluate a comprehensive set of reconstruction methods after C-2 resection to determine the optimal configuration depending on the degree of excision required.

Methods

Eight human heads (from the skull to C-6) from 4 males and 4 females with a mean age of 68 ± 18 years at death were cleaned of tissue, while leaving ligaments and discs intact. Nondestructive flexion and extension (FE), lateral bending (LB), and axial rotation (AR) tests were conducted using a nonconstraining, pure moment loading apparatus, and relative motion across the fusion site (C1–3) was measured using a 3D motion tracking system. Specimens were tested up to 1.5 Nm at 0.25-Nm intervals for 45 seconds each. The spines were instrumented using 3.5-mm titanium rods with a midline occipitocervical plate (4.0 × 12–mm screws) and lateral mass screws (excluding C-2) at the C-1 (3.0 × 40 mm) and C3–5 levels (3.0 × 16 mm). Testing was repeated for the following configurations: Configuration 1 (CF1), instrumentation only from occiput to C-5; CF2, C-2 corpectomy leaving the dens; CF3, titanium mesh cage (16-mm diameter) from C-3 to C-1 ring and dens; CF4, removal of cage, C-1 ring, and dens; CF5, titanium mesh cage from C-3 to clivus (16-mm diameter); CF6, removal of C-2 posterior elements leaving the C3–clivus cage (spondylectomy); CF7, titanium mesh cage from C-3 to clivus (16-mm diameter) with 2 titanium mesh cages from C-3 to C-1 lateral masses (12-mm diameter); and CF8, removal of all 3 cages. A crosslink was added connecting the posterior rods for CF1, CF6, and CF8. Range-of-motion (ROM) differences between all groups were compared via repeated-measures ANOVA with paired comparisons using the Student t-test with a Tukey post hoc adjustment. A p < 0.05 indicated significance.

Results

The addition of a central cage significantly increased FE rigidity compared with posterior instrumentation alone but had less of an effect in AR and LB. The addition of lateral cages did not significantly improve rigidity in any bending direction (CF6 vs CF7, p > 0.05). With posterior instrumentation alone (CF1 and CF2), C-2 corpectomy reduced bending rigidity in only the FE direction (p < 0.05). The removal of C-2 posterior elements in the presence of a C3–clivus cage did not affect the ROM in any bending mode (CF5 vs CF6, p > 0.05). A crosslink addition in CF1, CF6, and CF8 did not significantly affect primary or off-axis ROM (p > 0.05).

Conclusions

Study results indicated that posterior instrumentation alone with 3.5-mm rods is insufficient for stability restoration after a C-2 corpectomy. Either C3–1 or C3–clivus cages can correct instability introduced by C-2 removal in the presence of posterior instrumentation. The addition of lateral cages to a C3–clivus fusion construct may be unnecessary since it does not significantly improve rigidity in any direction.

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Justin K. Scheer, Jessica A. Tang, Justin S. Smith, Frank L. Acosta Jr., Themistocles S. Protopsaltis, Benjamin Blondel, Shay Bess, Christopher I. Shaffrey, Vedat Deviren, Virginie Lafage, Frank Schwab, Christopher P. Ames and the International Spine Study Group

This paper is a narrative review of normal cervical alignment, methods for quantifying alignment, and how alignment is associated with cervical deformity, myelopathy, and adjacent-segment disease (ASD), with discussions of health-related quality of life (HRQOL). Popular methods currently used to quantify cervical alignment are discussed including cervical lordosis, sagittal vertical axis, and horizontal gaze with the chin-brow to vertical angle. Cervical deformity is examined in detail as deformities localized to the cervical spine affect, and are affected by, other parameters of the spine in preserving global sagittal alignment. An evolving trend is defining cervical sagittal alignment. Evidence from a few recent studies suggests correlations between radiographic parameters in the cervical spine and HRQOL. Analysis of the cervical regional alignment with respect to overall spinal pelvic alignment is critical. The article details mechanisms by which cervical kyphotic deformity potentially leads to ASD and discusses previous studies that suggest how postoperative sagittal malalignment may promote ASD. Further clinical studies are needed to explore the relationship of cervical malalignment and the development of ASD. Sagittal alignment of the cervical spine may play a substantial role in the development of cervical myelopathy as cervical deformity can lead to spinal cord compression and cord tension. Surgical correction of cervical myelopathy should always take into consideration cervical sagittal alignment, as decompression alone may not decrease cord tension induced by kyphosis. Awareness of the development of postlaminectomy kyphosis is critical as it relates to cervical myelopathy. The future direction of cervical deformity correction should include a comprehensive approach in assessing global cervicalpelvic relationships. Just as understanding pelvic incidence as it relates to lumbar lordosis was crucial in building our knowledge of thoracolumbar deformities, T-1 incidence and cervical sagittal balance can further our understanding of cervical deformities. Other important parameters that account for the cervical-pelvic relationship are surveyed in detail, and it is recognized that all such parameters need to be validated in studies that correlate HRQOL outcomes following cervical deformity correction.

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Christopher P. Ames, Justin S. Smith, Justin K. Scheer, Christopher I. Shaffrey, Virginie Lafage, Vedat Deviren, Bertrand Moal, Themistocles Protopsaltis, Praveen V. Mummaneni, Gregory M. Mundis Jr., Richard Hostin, Eric Klineberg, Douglas C. Burton, Robert Hart, Shay Bess, Frank J. Schwab and the International Spine Study Group

Object

Cervical spine osteotomies are powerful techniques to correct rigid cervical spine deformity. Many variations exist, however, and there is no current standardized system with which to describe and classify cervical osteotomies. This complicates the ability to compare outcomes across procedures and studies. The authors' objective was to establish a universal nomenclature for cervical spine osteotomies to provide a common language among spine surgeons.

Methods

A proposed nomenclature with 7 anatomical grades of increasing extent of bone/soft tissue resection and destabilization was designed. The highest grade of resection is termed the major osteotomy, and an approach modifier is used to denote the surgical approach(es), including anterior (A), posterior (P), anterior-posterior (AP), posterior-anterior (PA), anterior-posterior-anterior (APA), and posterior-anterior-posterior (PAP). For cases in which multiple grades of osteotomies were performed, the highest grade is termed the major osteotomy, and lower-grade osteotomies are termed minor osteotomies. The nomenclature was evaluated by 11 reviewers through 25 different radiographic clinical cases. The review was performed twice, separated by a minimum 1-week interval. Reliability was assessed using Fleiss kappa coefficients.

Results

The average intrarater reliability was classified as “almost perfect agreement” for the major osteotomy (0.89 [range 0.60–1.00]) and approach modifier (0.99 [0.95–1.00]); it was classified as “moderate agreement” for the minor osteotomy (0.73 [range 0.41–1.00]). The average interrater reliability for the 2 readings was the following: major osteotomy, 0.87 (“almost perfect agreement”); approach modifier, 0.99 (“almost perfect agreement”); and minor osteotomy, 0.55 (“moderate agreement”). Analysis of only major osteotomy plus approach modifier yielded a classification that was “almost perfect” with an average intrarater reliability of 0.90 (0.63–1.00) and an interrater reliability of 0.88 and 0.86 for the two reviews.

Conclusions

The proposed cervical spine osteotomy nomenclature provides the surgeon with a simple, standard description of the various cervical osteotomies. The reliability analysis demonstrated that this system is consistent and directly applicable. Future work will evaluate the relationship between this system and health-related quality of life metrics.

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Shayan Fakurnejad, Justin K. Scheer, Virginie Lafage, Justin S. Smith, Vedat Deviren, Richard Hostin, Gregory M. Mundis Jr., Douglas C. Burton, Eric Klineberg, Munish Gupta, Khaled Kebaish, Christopher I. Shaffrey, Shay Bess, Frank Schwab, Christopher P. Ames and The International Spine Study Group

OBJECT

Three-column osteotomies (3COs) are technically challenging techniques for correcting severe rigid spinal deformities. The impact of these interventions on outcomes reaching minimum clinically important difference (MCID) or substantial clinical benefit (SCB) is unclear. The objective of this study was to determine the rates of MCID and SCB in standard health-related quality of life (HRQOL) measures after 3COs in patients with adult spinal deformity (ASD). The impacts of location of the uppermost instrumented vertebra (UIV) on clinical outcomes and of maintenance on sagittal correction at 2 years postoperatively were also examined.

METHODS

The authors conducted a retrospective multicenter analysis of the records from adult patients who underwent 3CO with complete 2-year radiographic and clinical follow-ups. Cases were categorized according to established radiographic thresholds for pelvic tilt (> 22°), sagittal vertical axis (> 4.7 cm), and the mismatch between pelvic incidence and lumbar lordosis (> 11°). The cases were also analyzed on the basis of a UIV in the upper thoracic (T1–6) or thoracolumbar (T9–L1) region. Patient-reported outcome measures evaluated preoperatively and 2 years postoperatively included Oswestry Disability Index (ODI) scores, the Physical Component Summary and Mental Component Summary (MCS) scores of the 36-Item Short Form Health Survey, and Scoliosis Research Society-22 questionnaire (SRS-22) scores. The percentages of patients whose outcomes for these measures met MCID and SCB were compared among the groups.

RESULTS

Data from 140 patients (101 women and 39 men) were included in the analysis; the average patient age was 57.3 ± 12.4 years (range 20–82 years). Of these patients, 94 had undergone only pedicle subtraction osteotomy (PSO) and 42 only vertebral column resection (VCR); 113 patients had a UIV in the upper thoracic (n = 63) orthoracolumbar region (n = 50). On average, 2 years postoperatively the patients had significantly improved in all HRQOL measures except the MCS score. For the entire patient cohort, the improvements ranged from 57.6% for the SRS-22 pain score MCID to 24.4% for the ODI score SCB. For patients undergoing PSO or VCR, the likelihood of their outcomes reaching MCID or SCB ranged from 24.3% to 62.3% and from 16.2% to 47.8%, respectively. The SRS-22 self-image score of patients who had a UIV in the upper thoracic region reached MCID significantly more than that of patients who had a UIV in the thoracolumbar region (70.6% vs 41.9%, p = 0.0281). All other outcomes were similar for UIVs of upper thoracic and thoracolumbar regions. Comparison of patients whose spines were above or below the radiographic thresholds associated with disability indicated similar rates of meeting MCID and SCB for HRQOL at the 2-year follow-up.

CONCLUSIONS

Outcomes for patients having UIVs in the upper thoracic region were no more likely to meet MCID or SCB than for those having UIVs in the thoracolumbar region, except for the MCID in the SRS-22 self-image measure. The HRQOL outcomes in patients who had optimal sagittal correction according to radiographic thresholds determined preoperatively were not significantly more likely to reach MCID or SCB at the 2-year follow-up. Future work needs to determine whether the Schwab preoperative radiographic thresholds for severe disability apply in postoperative settings.

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Justin K. Scheer, Jessica A. Tang, Justin S. Smith, Eric Klineberg, Robert A. Hart, Gregory M. Mundis Jr., Douglas C. Burton, Richard Hostin, Michael F. O'Brien, Shay Bess, Khaled M. Kebaish, Vedat Deviren, Virginie Lafage, Frank Schwab, Christopher I. Shaffrey, Christopher P. Ames and the International Spine Study Group

Object

Complications and reoperation for surgery to correct adult spinal deformity are not infrequent, and many studies have analyzed the rates and factors that influence the likelihood of reoperation. However, there is a need for more comprehensive analyses of reoperation in adult spinal deformity surgery from a global standpoint, particularly focusing on the 1st year following operation and considering radiographic parameters and the effects of reoperation on health-related quality of life (HRQOL). This study attempts to determine the prevalence of reoperation following surgery for adult spinal deformity, assess the indications for these reoperations, evaluate for a relation between specific radiographic parameters and the need for reoperation, and determine the potential impact of reoperation on HRQOL measures.

Methods

A retrospective review was conducted of a prospective, multicenter, adult spinal deformity database collected through the International Spine Study Group. Data collected included age, body mass index, sex, date of surgery, information regarding complications, reoperation dates, length of stay, and operation time. The radiographic parameters assessed were total number of levels instrumented, total number of interbody fusions, C-7 sagittal vertical axis, uppermost instrumented vertebra (UIV) location, and presence of 3-column osteotomies. The HRQOL assessment included Oswestry Disability Index (ODI), 36-Item Short Form Health Survey physical component and mental component summary, and SRS-22 scores. Smoking history, Charlson Comorbidity Index scores, and American Society of Anesthesiologists Physical Status classification grades were also collected and assessed for correlation with risk of early reoperation. Various statistical tests were performed for evaluation of specific factors listed above, and the level of significance was set at p < 0.05.

Results

Fifty-nine (17%) of a total of 352 patients required reoperation. Forty-four (12.5%) of the reoperations occurred within 1 year after the initial surgery, including 17 reoperations (5%) within 30 days.

Two hundred sixty-eight patients had a minimum of 1 year of follow-up. Fifty-three (20%) of these patients had a 3-column osteotomy, and 10 (19%) of these 53 required reoperation within 1 year of the initial procedure. However, 3-column osteotomy was not predictive of reoperation within 1 year, p = 0.5476). There were no significant differences between groups with regard to the distribution of UIV, and UIV did not have a significant effect on reoperation rates. Patients needing reoperation within 1 year had worse ODI and SRS-22 scores measured at 1-year follow-up than patients not requiring operation.

Conclusions

Analysis of data from a large multicenter adult spinal deformity database shows an overall 17% reoperation rate, with a 19% reoperation rate for patients treated with 3-column osteotomy and a 16% reoperation rate for patients not treated with 3-column osteotomy. The most common indications for reoperation included instrumentation complications and radiographic failure. Reoperation significantly affected HRQOL outcomes at 1-year follow-up. The need for reoperation may be minimized by carefully considering spinal alignment, termination of fixation, and type of surgical procedure (presence of osteotomy). Precautions should be taken to avoid malposition or instrumentation (rod) failure.