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Zachary J. Tempel, Gurpreet S. Gandhoke, Christopher M. Bonfield, David O. Okonkwo and Adam S. Kanter

relation to lumbar lordosis. Both patients who had previously undergone implantation of intrathecal opioid pumps had their pumps removed within 1 year after definitive corrective surgery. Numerous studies have also investigated regional lumbar lordosis, which is directly related to global sagittal alignment. 12 , 20 , 22 , 57 Studies have found the normal range for lumbar lordosis to be 42°–66°. 24 Loss of lordosis is poorly tolerated in the lumbar spine, 16 , 48 , 50 and its maintenance is critical to better achieve global sagittal balance. Lumbar lordosis is

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Fred C. Lam, Adam S. Kanter, David O. Okonkwo, James W. Ogilvie and Praveen V. Mummaneni

colleagues 13 , 14 first reported the use of carbon fiber cages in PLIF. 118 Hoshijima et al. 48 and Eck and associates 34 reported their experiences with titanium mesh cages in PLIF and ALIF surgery, respectively, with reasonable fusion rates and maintenance of lordosis in the latter 1990s. In 2002, Lenke and Bridwell 63 reviewed their experience with the use of mesh cages in the treatment of 130 patients with AIS and reported adequate sagittal alignment and an acceptable pseudarthrosis rate. Equal efficacy was reported in the adult population by Eck et al. 35 in

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Adam S. Kanter, David S. Bradford, David O. Okonkwo, Setti S. Rengachary and Praveen V. Mummaneni

in place of Dwyer's cables and placing the screws more posteriorly to enhance de-rotation and reduce kyphosis. This strategy provided more durable fixation with spinal de-rotation and fewer fixed segments and therefore fewer flat backs, ultimately leading to superior sagittal alignment as well. 41 Early enthusiasm was once again blunted by criticism as long-term results revealed pseudarthrosis and hardware failure rates of 23%, likely due to the limited durability of a single rod system. Hall attempted to strengthen the fusion construct by modifying Moe's facet

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Matthew J. Tormenti, Matthew B. Maserati, Christopher M. Bonfield, David O. Okonkwo and Adam S. Kanter

idiopathic scoliosis . Spine 14 : 1391 – 1397 , 1989 11 Jagannathan J , Sansur CA , Oskouian RJ Jr , Fu KM , Shaffrey CI : Radiographic restoration of lumbar alignment after transforaminal lumbar interbody fusion . Neurosurgery 64 : 955 – 964 , 2009 12 Jang JS , Lee SH , Min JH , Maeng DH : Changes in sagittal alignment after restoration of lower lumbar lordosis in patients with degenerative flat back syndrome . J Neurosurg Spine 7 : 387 – 392 , 2007 13 Lane JD Jr , Moore ES Jr : Transperitoneal approach to the

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Zachary J. Tempel, Michael M. McDowell, David M. Panczykowski, Gurpreet S. Gandhoke, D. Kojo Hamilton, David O. Okonkwo and Adam S. Kanter

fusion with pedicle screw fixation . Orthopedics 32 : 32 , 2009 42 Tomé-Bermejo F , Morales-Valencia JA , Moreno-Pérez J , Marfil-Pérez J , Díaz-Dominguez E , Piñera AR , : Degenerative cervical disc disease: long-term changes in sagittal alignment and their clinical implications after cervical interbody fusion cage subsidence: a prospective study with stand-alone lordotic tantalum cages . J Clin Spine Surg 30 : E648 – E655 , 2017 43 Tormenti MJ , Maserati MB , Bonfield CM , Okonkwo DO , Kanter AS : Complications and

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The comprehensive anatomical spinal osteotomy and anterior column realignment classification

Presented at the 2018 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Juan S. Uribe, Frank Schwab, Gregory M. Mundis Jr., David S. Xu, Jacob Januszewski, Adam S. Kanter, David O. Okonkwo, Serena S. Hu, Deviren Vedat, Robert Eastlack, Pedro Berjano and Praveen V. Mummaneni

lordosis (LL) within 10° of the pelvic incidence (PI). 5 , 12 , 13 , 15 , 18 , 28 , 29 Traditionally, varying posterior shortening osteotomies were performed to release and reconstruct the spine to achieve appropriate sagittal alignment and spinopelvic harmony. Schwab et al. recently classified osteotomies from the posterior approach. 27 The classification is anatomically based with graduated complexity that ranges from simple inferior facet resection to those including pedicle subtraction osteotomy and vertebral column resection at 1 or more levels. Minimally invasive

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Nitin Agarwal, Federico Angriman, Ezequiel Goldschmidt, James Zhou, Adam S. Kanter, David O. Okonkwo, Peter G. Passias, Themistocles Protopsaltis, Virginie Lafage, Renaud Lafage, Frank Schwab, Shay Bess, Christopher Ames, Justin S. Smith, Christopher I. Shaffrey, Douglas Burton, D. Kojo Hamilton and the International Spine Study Group

single center (New York University Hospital for Joint Disease). Explanatory Variables and Outcomes The primary outcome was change in global sagittal alignment at 1 year after surgery. The primary independent variable considered was baseline (preoperative) BMI. Additional important clinical predictors extracted included age, sex, smoking status, active malignancy, chronic lung disease, chronic arthritis, and major depression. Secondary outcomes included HRQoL determined by use of the ODI and SRS-22. Statistical Analysis Descriptive statistics were used to determine

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Alexander A. Theologis, Gregory M. Mundis Jr., Stacie Nguyen, David O. Okonkwo, Praveen V. Mummaneni, Justin S. Smith, Christopher I. Shaffrey, Richard Fessler, Shay Bess, Frank Schwab, Bassel G. Diebo, Douglas Burton, Robert Hart, Vedat Deviren and Christopher Ames

patients (mean preoperative Cobb angle 38.9°) treated with multilevel minimally invasive LIF (mean 2.8 levels per patient) and open PSF, the postoperative average Cobb angle was 13.4°. 33 In their comparative group, consisting of 4 patients who underwent posterior-only instrumentation combined with posterior interbody fusion at a variable number of levels (ranging from none to 3 levels), the mean values for curve correction were lower than in patients treated with the combination of minimally invasive LIF and open PSF. 33 Regional sagittal alignment is not

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Paul Park, Michael Y. Wang, Virginie Lafage, Stacie Nguyen, John Ziewacz, David O. Okonkwo, Juan S. Uribe, Robert K. Eastlack, Neel Anand, Raqeeb Haque, Richard G. Fessler, Adam S. Kanter, Vedat Deviren, Frank La Marca, Justin S. Smith, Christopher I. Shaffrey, Gregory M. Mundis Jr. and Praveen V. Mummaneni

, including adult spinal deformity (ASD). Anand et al. 3 initially reported the feasibility of applying several different MIS techniques to treat symptomatic lumbar scoliosis. Subsequent reports have all confirmed successful MIS treatment of ASD. 5 , 17 , 21 , 24 These studies, however, have been limited by the relatively small numbers of patients evaluated, as well as the lack of focus on sagittal alignment and spinopelvic parameters, which are factors known to significantly impact long-term disability. 12 , 18 In addition, there has been no uniform MIS technique or

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Khoi D. Than, Paul Park, Kai-Ming Fu, Stacie Nguyen, Michael Y. Wang, Dean Chou, Pierce D. Nunley, Neel Anand, Richard G. Fessler, Christopher I. Shaffrey, Shay Bess, Behrooz A. Akbarnia, Vedat Deviren, Juan S. Uribe, Frank La Marca, Adam S. Kanter, David O. Okonkwo, Gregory M. Mundis Jr., Praveen V. Mummaneni and the International Spine Study Group

that the spines of patients who do the worst are not appropriately corrected in the sagittal plane and are perhaps fused into a fixed sagittal plane deformity. The increased mean SVA in both groups probably represents the limited ability to improve sagittal alignment with early MIS techniques. Similarly, the unchanged PILL mismatch in the worst group reflects a lack of sagittal alignment improvement obtained by the early MIS approaches we used. These results highlight the basis of the MISDEF algorithm we created to guide MIS versus open treatment in patients with