Adult spinal deformity surgery: posterior three-column osteotomies vs anterior lordotic cages with posterior fusion. Complications, clinical and radiological results. A systematic review of the literature

Purpose The aim of our study is to analyse mid- to long-term severe adult spinal deformity (ASD) surgery outcomes by comparing three-column osteotomies (3CO) and multiple anterior interbody fusion cages (AC). Materials and methods The PRISMA flowchart was used to systematically review the literature. Only articles with a minimum 24-month follow-up were examined, and 11 articles were included. The following radiological parameters were observed: pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL), sagittal vertical axis (SVA), Cobb angle and T1-sacrum plumbline. Clinical outcome was assessed using the visual analogue scale (VAS) and Oswestry disability index (ODI) scores. The main complications were analysed, and the two groups were compared. Results Except for age, the two populations were homogeneous. Both techniques had the same number of posterior instrumented levels (7.4 +/- 1.7). The AC group had a mean 3 +/- 1.4 interbody fusions per patient. In the PSO group, all patients had 1 3CO and 89.8% of the osteotomies were performed at L2 or L3 vertebrae. No difference was observed between the two groups in terms of clinical outcomes. Both techniques were effective in sagittal parameters restoration with a final PI-LL mismatch = 4.4 degrees. The PSO group had a statistically higher rate of intraoperative blood loss (p = 0.036), major complications, pseudoarthrosis and dural tears (p < 0.001). Conclusion Both PSO and multiple AC are effective in treating ASD. Multiple AC seems more suitable when treating older patients because of a lower intraoperative blood loss, lower rate of major complications and fewer number of revision surgeries.