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Anterior Elongation as a Minimally Invasive Alternative for Sagittal Imbalance—A Case Series

An Erratum to this article was published on 20 June 2012



Degenerative and iatrogenic conditions may lead to flat back or even to kyphotic deformity, and sagittal imbalance can cause significant clinical impairment. Minor imbalance cases are usually treated with conservative care. Among currently popular surgical techniques for the correction of sagittal imbalance are posterior-based procedures, which are associated with access-related risks (mostly neurological) and postoperative morbidity risks.


This study aims to report a minimally invasive lateral approach using hyperlordotic cages in the treatment of mild sagittal imbalance. Radiological correction, clinical improvement, and safety will be analyzed.


Eight patients (mean age 71.8 years, SD 7.8; mean BMI 27.5, SD 2.3) with symptomatic sagittal imbalance were retrospectively reviewed. Eight cases were treated by anterior interbody fusion with lordotic cages. A minimally invasive lateral retroperitoneal approach was used in the surgical procedures, with or without percutaneous pedicle screw supplementation.


No major complications occurred and just one case needed revision for direct decompression. Clinical outcomes Visual Analog Scale score changed from 88 at preoperative visit to 51 at 1-week visit, and Oswestry Disability Index score decreased from 82 at preoperative visit to 44 at 6-week visit. The 6-month radiological assessment revealed improvement in spinopelvic parameters: Focal lordosis improved from 2.3° ± 7.7 to 27.1° ± 6.7. Sagittal vertical alignment improved from 11.7 ± 5.3 to 6.2 ± 4.0 cm. Preoperative sacral slope improved from 20.1° ± 5.8 to 29.4° ± 10.3 and preoperative pelvic tilt improved from 35.2° ± 5.2 to 23.8° ± 4.3. Short-term results indicate that the minimally invasive lateral approach can be applied to the treatment of mild sagittal imbalance, with special advantage in elderly patients or those in which posterior approaches are relatively contraindicated.

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Portions of this work, including early and interim reports, were presented in abstract/poster/oral presentation form at the Society of Lateral Access Surgery (SOLAS) in Mar 31, 2011; San Diego, California; the Spine Arthroplasty Society (SAS) in April 28, 2010; New Orleans, Louisiana; North America Spine Society (NASS) in October 6, 2010; Orlando, Florida; and Congress of Neurological Surgeons (CNS) in October 20, 2010; San Francisco, California; as well at the Honorary and Distinguished Lecture at the Hospital for Special Surgery (HSS) June 3 2011; New York, New York.


One of the authors (L.P.) certifies that he or she has received or may receive payments or benefits from NuVasive, Inc. Other authors have nothing to disclose.

Each author certifies that his or her institution has approved the reporting of these cases, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participating in the study was obtained.

Work was performed at Instituto de Patologia da Coluna, São Paulo, Brazil.

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Correspondence to Luiz Pimenta MD, PhD.

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Level of Evidence: Level IV retrospective case series.

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Marchi, L., Oliveira, L., Amaral, R. et al. Anterior Elongation as a Minimally Invasive Alternative for Sagittal Imbalance—A Case Series. HSS Jrnl 8, 122–127 (2012).

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  • spine
  • lumbar spine
  • spine fusion
  • sagittal balance
  • minimally invasive surgery
  • interbody fusion