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Anterior Column Realignment (ACR): Minimally Invasive Surgery for the Treatment of Adult Sagittal Plane Deformity

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Minimally Invasive Spine Surgery

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Abstract

Adult sagittal plane alignment is the result of an intricate interaction between the spine and pelvis. The development of a sagittal spine deformity results in a series of compensatory mechanisms including increase in pelvic tilt, hip extensor overutilization, and knee and ankle flexion. When these natural mechanisms fail, patients may develop symptomatic sagittal imbalance, which ultimately affects their function and quality of life.

Traditional techniques to address sagittal spine deformity include posterior-based spine osteotomies to restore the sagittal balance. Historically, however, these techniques have been associated with a high morbidity, long operative times, and excessive blood loss.

This chapter focuses on the treatment of sagittal spinal deformity using a novel minimally invasive technique, anterior column realignment (ACR). The technique utilizes a retroperitoneal approach to the lumbar spine with lateral interbody fusion after releasing the anterior longitudinal ligament (ALL) and annulus to restore focal sagittal alignment. Attention to case selection and technical pearls of the ACR is of utmost importance to achieve desirable outcomes and avoid catastrophic complications.

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Author information

Authors and Affiliations

  1. Scripps Clinic Torrey Pines, La Jolla, CA, USA

    Gregory M. Mundis Jr.

  2. Department of Orthopedics, San Diego Spine Foundation, San Diego, CA, USA

    Gregory M. Mundis Jr., Pooria Hosseini & Behrooz A. Akbarnia

  3. Department of Orthopedics, Scripps Hospital, La Jolla, CA, USA

    Gregory M. Mundis Jr. & Amrit Khalsa

Authors
  1. Gregory M. Mundis Jr.
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  2. Pooria Hosseini
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  3. Amrit Khalsa
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  4. Behrooz A. Akbarnia
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Editor information

Editors and Affiliations

  1. Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA

    Frank M. Phillips

  2. Texas Back Institute Texas Health Presbyterian Hospital Plano Scoliosis and Spine Tumor Center, Plano, TX, USA

    Isador H. Lieberman

  3. Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA

    David W. Polly Jr.

  4. Department of Neurological Surgery, University of Miami/Jackson Memorial Hospital, Miami, FL, USA

    Michael Y. Wang

Appendices

Quiz Questions

  1. 1.

    What are the realignment objectives for sagittal plane correction in general?

    1. (a)

      PT <20°, SVA <50 mm, T1SPI <0, and LL = PI ± 10°

    2. (b)

      PT <30°, SVA <50 mm, T1SPI <0, and LL = PI ± 10°

    3. (c)

      PT <20°, SVA <100 mm, T1SPI <0, and LL = PI ± 10°

    4. (d)

      PT <20°, SVA <100 mm, T1SPI <0, and LL = PI ± 20°

  2. 2.

    Intraoperatively, if there is any concern for the possibility of vascular injury, what is the best first management option?

    1. (a)

      A determination should be made whether the bleeding is venous or arterial

    2. (b)

      The suspicious site should be packed immediately.

    3. (c)

      The appropriate consultations should be initiated to safely correct the vascular injury if there is an arterial tear.

    4. (d)

      All of the above

  3. 3.

    What will be the status of HRQOL outcomes in a patient with sympathetic dysfunction complication after anterior column realignment (ACR) surgery?

    1. (a)

      Improves

    2. (b)

      Worsens

    3. (c)

      Doesn’t change

    4. (d)

      There is not enough evidence to answer the question

  4. 4.

    Based on Glassman et al., what is the most important and reliable radiographic predictor of worsened clinical health status in patients both with and without previous spine surgery?

    1. (a)

      Positive sagittal balance

    2. (b)

      PI-LL mismatch

    3. (c)

      SVA <50 mm

    4. (d)

      Thoracic hyperkyphosis

Answers

  1. 1.

    a

  2. 2.

    b

  3. 3.

    c

  4. 4.

    a

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Mundis, G.M., Hosseini, P., Khalsa, A., Akbarnia, B.A. (2019). Anterior Column Realignment (ACR): Minimally Invasive Surgery for the Treatment of Adult Sagittal Plane Deformity. In: Phillips, F., Lieberman, I., Polly Jr., D., Wang, M. (eds) Minimally Invasive Spine Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-19007-1_39

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  • DOI: https://doi.org/10.1007/978-3-030-19007-1_39

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-19006-4

  • Online ISBN: 978-3-030-19007-1

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