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Contemporary utilization of three-column osteotomy techniques in a prospective complex spinal deformity multicenter database: implications on full-body alignment and perioperative course

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Research has focused on the increased correction from a three-column osteotomy (3CO) during adult spinal deformity (ASD) surgery. However, an in-depth analysis on the performance of a 3CO in a cohort of complex spinal deformity cases has not been described.

Study design/setting

This is a retrospective study on a prospectively enrolled, complex ASD database.


This study aimed to determine if three-column osteotomies demonstrate superior benefit in correction of complex sagittal deformity at the cost of increased perioperative complications.


Surgical complex adult spinal deformity patients were included and grouped into thoracolumbar 3COs compared to those who did not have a 3CO (No 3CO) (remaining cohort). Rigid deformity was defined as ΔLL less than 33% from standing to supine. Severe deformity was defined as global (SVA > 70 mm) or C7-PL > 70 mm, or lumbopelvic (PI-LL > 30°). Means comparison tests assessed correction by 3CO grade/location. Multivariate analysis controlling for baseline deformity evaluated outcomes up to six weeks compared to No 3CO.


648 patients were included (Mean age 61 ± 14.6 years, BMI 27.55 ± 5.8 kg/m2, levels fused: 12.6 ± 3.8). 126 underwent 3CO, a 20% higher usage than historical cohorts. 3COs were older, frail, and more likely to undergo revision (OR 5.2, 95% CI [2.6–10.6]; p < .001). 3COs were more likely to present with both severe global/lumbopelvic deformity (OR 4), 62.4% being rigid. 3COs had greater use of secondary rods (OR 4st) and incurred 4 times greater risk for: massive blood loss (> 3500 mL), longer LOS, SICU admission, perioperative wound and spine-related complications, and neurologic complications when performed below L3. 3COs had similar HRQL benefit, but higher perioperative opioid use. Mean segmental correction increased by grade (G3–21; G4–24; G5–27) and was 4 × greater than low-grade osteotomies, especially below L3 (OR 12). 3COs achieved 2 × greater spinopelvic correction. Higher grades properly distributed lordosis 50% of the time except L5. Pelvic compensation and non-response were relieved more often with increasing grade, with greater correction in all lower extremity parameters (p < .01). Due to the increased rate of complications, 3COs trended toward higher perioperative cost ($42,806 vs. $40,046, p = .086).


Three-column osteotomy usage in contemporary complex spinal deformities is generally limited to more disabled individuals undergoing the most severe sagittal and coronal realignment procedures. While there is an increased perioperative cost and prolongation of length of stay with usage, these techniques represent the most powerful realignment techniques available with a dramatic impact on normalization at operative levels and reciprocal changes.

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Data availability

The data used in this study is not publicly available, but institution-specific data may be available upon request from the different institutions involved in this study.


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The International Spine Study Group (ISSG) is funded through research grants from DePuy Synthes and individual donations.

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Authors and Affiliations




The authors made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the creation of new software used in the work; drafted the work or revised it critically for important intellectual content; approved the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; Tyler K. Williamson and Peter Passias contributed to conception and design and drafting of the manuscript; Tyler K. Williamson, Jamshaid Mir, Justin Smith, Virginie Lafage, Renaud Lafage, Breton Line, Bassel Diebo, Alan Daniels, Jeffrey Gum, D. Kojo Hamilton, Justin Scheer, Robert Eastlack, Andreas Demetriades, Khaled Kebaish, Stephen Lewis, Lawrence Lenke, Richard Hostin, Munish Gupta, Han Jo Kim, Christopher Ames, Douglas Burton, Christopher Shaffrey, Eric Klineberg, Shay Bess, and Peter Passias performed acquisition, analysis, and interpretation of data and critical revision of the manuscript for important intellectual content; approved the version to be published; and agree to be accountable for all aspects of the work; Tyler K. Williamson was involved in statistical analysis; Peter Passias was involved in administrative, technical, or material support and did supervision.

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Correspondence to Peter G. Passias.

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Ethical approval

Institutional Review Board approval was obtained before enrolling patients in the prospective database. Informed consent was obtained from each patient prior to enrollment.

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Informed consent was obtained from all individual participants included in this study.

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Williamson, T.K., Mir, J.M., Smith, J.S. et al. Contemporary utilization of three-column osteotomy techniques in a prospective complex spinal deformity multicenter database: implications on full-body alignment and perioperative course. Spine Deform (2024).

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