{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,29]],"date-time":"2026-01-29T22:36:14Z","timestamp":1769726174957,"version":"3.49.0"},"reference-count":36,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"1","license":[{"start":{"date-parts":[[2025,7,7]],"date-time":"2025-07-07T00:00:00Z","timestamp":1751846400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Cosmet Laser Ther"],"published-print":{"date-parts":[[2025,7,7]]},"abstract":"\n BACKGROUND<\/jats:title>\n Iatrogenic flat back syndrome following prior posterolateral fusion without interbody support is challenging, especially with adjacent segment stenosis. While pedicle subtraction osteotomy (PSO) offers strong correction, it is associated with higher morbidity. Alternative techniques with reduced risk are needed.<\/jats:p>\n <\/jats:sec>\n \n OBSERVATIONS<\/jats:title>\n The authors present the case of a 71-year-old woman with a 25-year-old L4\u2013S1 fusion and severe sagittal deformity who underwent a Schwab grade 2 posterior column osteotomy (PCO) through the L4\u20135 fusion mass, with insertion of interbody cages of varying heights and lordotic angles. Preoperative parameters included C7 sagittal vertical axis (SVA) +10 cm, pelvic incidence (PI) 65\u00b0, lumbar lordosis (LL) \u221213\u00b0, PI-LL mismatch 79\u00b0, and pelvic tilt (PT) 43\u00b0. Postoperative improvements were C7 SVA +5.7 cm, LL 41\u00b0, PI-LL mismatch 24\u00b0, and PT 35\u00b0. The 285-minute surgery had an estimated blood loss of 1100 mL. At 1 month, the patient could walk a one-quarter mile, compared with < 50 feet before surgery.<\/jats:p>\n <\/jats:sec>\n \n LESSONS<\/jats:title>\n This modified PCO technique provides effective decompression and substantial sagittal correction for iatrogenic flat back syndrome while potentially reducing morbidity compared with PSO. By distributing correction across multiple levels, this approach offers a valuable alternative for patients with moderate to severe sagittal imbalance and concurrent stenosis above prior fusion constructs\u2014avoiding a three-column osteotomy.<\/jats:p>\n \n https:\/\/thejns.org\/doi\/10.3171\/CASE25251<\/jats:ext-link>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/case25251","type":"journal-article","created":{"date-parts":[[2025,7,7]],"date-time":"2025-07-07T02:42:23Z","timestamp":1751856143000},"source":"Crossref","is-referenced-by-count":0,"title":["Posterior column osteotomy for spinal realignment in patients with prior lumbar fusion: illustrative case"],"prefix":"10.3171","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3346-1631","authenticated-orcid":true,"given":"Barnabas","family":"Obeng-Gyasi","sequence":"first","affiliation":[{"name":"Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anoop","family":"Chinthala","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michael J.","family":"Visconti","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ahmed M.","family":"Belal","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gordon","family":"Mao","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"2","key":"bib1","series-title":"Neurosurg Clin N Am","first-page":"289","article-title":"Flatback syndrome","volume":"18","author":"Lu","year":"2007","unstructured":"Lu DCChou D.Flatback syndrome. Neurosurg Clin N Am. 2007;18(2):289-294."},{"issue":"7","key":"bib2","series-title":"J Bone Joint Surg Am","first-page":"1053","article-title":"Late neurological complications of Harrington-rod instrumentation","volume":"71","author":"Hales","year":"1989","unstructured":"Hales DDDawson EGDelamarter R.Late neurological complications of Harrington-rod instrumentation. J Bone Joint Surg Am. 1989;71(7):1053-1057."},{"issue":"6","key":"bib3","series-title":"J Korean Neurosurg Soc","first-page":"615","article-title":"Surgical outcomes of post-fusion lumbar flatback deformity with sagittal imbalance","volume":"59","author":"Kim","year":"2016","unstructured":"Kim JSKim SM.Surgical outcomes of post-fusion lumbar flatback deformity with sagittal imbalance. J Korean Neurosurg Soc. 2016;59(6):615-621."},{"issue":"4","key":"bib4","series-title":"J Bone Joint Surg Am","first-page":"569","article-title":"Treatment of symptomatic flatback after spinal fusion","volume":"70","author":"Lagrone","year":"1988","unstructured":"Lagrone MOBradford DSMoe JHLonstein JEWinter RBOgilvie JW.Treatment of symptomatic flatback after spinal fusion. J Bone Joint Surg Am. 1988;70(4):569-580."},{"issue":"1","key":"bib5","series-title":"Spine (Phila Pa 1976)","first-page":"62","article-title":"Defining spino-pelvic alignment thresholds: should operative goals in adult spinal deformity surgery account for age?","volume":"41","author":"Lafage","year":"2016","unstructured":"Lafage RSchwab FChallier VDefining spino-pelvic alignment thresholds: should operative goals in adult spinal deformity surgery account for age? Spine (Phila Pa 1976). 2016;41(1):62-68."},{"issue":"2","key":"bib6","series-title":"Radiology","first-page":"341","article-title":"Spinal vacuum phenomena: anatomical study and review","volume":"139","author":"Resnick","year":"1981","unstructured":"Resnick DNiwayama GGuerra JJrVint VUsselman J.Spinal vacuum phenomena: anatomical study and review. Radiology. 1981;139(2):341-348."},{"issue":"2","key":"bib7","series-title":"Neurosurg Focus","first-page":"E15","article-title":"Correction of severe spinopelvic mismatch: decreased blood loss with lateral hyperlordotic interbody grafts as compared with pedicle subtraction osteotomy","volume":"43","author":"Leveque","year":"2017","unstructured":"Leveque JCYanamadala VBuchlak QDSethi RK.Correction of severe spinopelvic mismatch: decreased blood loss with lateral hyperlordotic interbody grafts as compared with pedicle subtraction osteotomy. Neurosurg Focus. 2017;43(2):E15."},{"issue":"1","key":"bib8","series-title":"J Neurosurg Spine","first-page":"56","article-title":"Pedicle subtraction osteotomy: a comprehensive analysis in 104 patients. Does the cause of deformity influence the outcome?","volume":"27","author":"Eskilsson","year":"2017","unstructured":"Eskilsson KSharma DJohansson CHedlund R.Pedicle subtraction osteotomy: a comprehensive analysis in 104 patients. Does the cause of deformity influence the outcome? J Neurosurg Spine. 2017;27(1):56-62."},{"issue":"6","key":"bib9","series-title":"Spine Deform","first-page":"656","article-title":"Complications of posterior column osteotomies in the pediatric spinal deformity patient","volume":"6","author":"Sze","year":"2018","unstructured":"Sze CHSmith JCLuhmann SJ.Complications of posterior column osteotomies in the pediatric spinal deformity patient. Spine Deform. 2018;6(6):656-661."},{"issue":"4","key":"bib10","series-title":"Glob Spine J","first-page":"654","article-title":"Revision strategies for Harrington Rod instrumentation: radiographic outcomes and complications","volume":"12","author":"Louie","year":"2022","unstructured":"Louie PKIyer SKhanna KRevision strategies for Harrington Rod instrumentation: radiographic outcomes and complications. Glob Spine J. 2022;12(4):654-662."},{"key":"bib11","series-title":"Stud Health Technol Inform","first-page":"306","article-title":"Efficacy of posterior only approach for complex iatrogenic flat back","volume":"280","author":"Martikos","year":"2021","unstructured":"Martikos KVommaro FBoriani LScarale AZarantonello PGreggi T.Efficacy of posterior only approach for complex iatrogenic flat back. Stud Health Technol Inform. 2021;280:306."},{"issue":"3","key":"bib12","series-title":"Curr Rev Musculoskelet Med","first-page":"305","article-title":"Lateral and oblique lumbar interbody fusion-current concepts and a review of recent literature","volume":"12","author":"Hah","year":"2019","unstructured":"Hah RKang HP.Lateral and oblique lumbar interbody fusion-current concepts and a review of recent literature. Curr Rev Musculoskelet Med. 2019;12(3):305-310."},{"issue":"suppl 5","key":"bib13","series-title":"Eur Spine J","first-page":"578","article-title":"Sagittal parameters of the spine: biomechanical approach","volume":"20","author":"Roussouly","year":"2011","unstructured":"Roussouly PPinheiro-Franco JL.Sagittal parameters of the spine: biomechanical approach. Eur Spine J. 2011;20(suppl 5):578-585."},{"issue":"6","key":"bib14","series-title":"Neurosurg Focus","first-page":"E5","article-title":"Relative lumbar lordosis and lordosis distribution index: individualized pelvic incidence-based proportional parameters that quantify lumbar lordosis more precisely than the concept of pelvic incidence minus lumbar lordosis","volume":"43","author":"Yilgor","year":"2017","unstructured":"Yilgor CSogunmez NYavuz YRelative lumbar lordosis and lordosis distribution index: individualized pelvic incidence-based proportional parameters that quantify lumbar lordosis more precisely than the concept of pelvic incidence minus lumbar lordosis. Neurosurg Focus. 2017;43(6):E5."},{"issue":"9","key":"bib15","series-title":"Clin Spine Surg","first-page":"E466","article-title":"Correlation between postoperative distribution of lordosis and reciprocal progression of thoracic kyphosis and occurrence of proximal junctional kyphosis following surgery for adult spinal deformity","volume":"31","author":"Ohba","year":"2018","unstructured":"Ohba TEbata SOba HKoyama KHaro H.Correlation between postoperative distribution of lordosis and reciprocal progression of thoracic kyphosis and occurrence of proximal junctional kyphosis following surgery for adult spinal deformity. Clin Spine Surg. 2018;31(9):E466-E472."},{"issue":"4","key":"bib16","series-title":"Neurospine","first-page":"1091","article-title":"New insights into risk factors for proximal junctional failure in adult spinal deformity surgery\u2014a commentary on \u201cproximal junctional failure development despite achieving ideal sagittal correction according to age-adjusted alignment target in patients with adult spinal deformity: risk factor analysis of 196 cases undergoing low thoracic to pelvic fusion","volume":"21","author":"Miyagi","year":"2024","unstructured":"Miyagi MInoue GTakaso M.New insights into risk factors for proximal junctional failure in adult spinal deformity surgery\u2014a commentary on \u201cproximal junctional failure development despite achieving ideal sagittal correction according to age-adjusted alignment target in patients with adult spinal deformity: risk factor analysis of 196 cases undergoing low thoracic to pelvic fusion.\u201d Neurospine. 2024;21(4):1091-1093."},{"issue":"3","key":"bib17","series-title":"Neurospine","first-page":"543","article-title":"Lordosis distribution index in short-segment lumbar spine fusion\u2014can ideal lordosis reduce revision surgery and iatrogenic deformity?","volume":"18","author":"Bari","year":"2021","unstructured":"Bari TJHeegaard MBech-Azeddine RDahl BGehrchen M.Lordosis distribution index in short-segment lumbar spine fusion\u2014can ideal lordosis reduce revision surgery and iatrogenic deformity? Neurospine. 2021;18(3):543-553."},{"issue":"6","key":"bib18","series-title":"Eur Spine J","first-page":"1388","article-title":"Effect of lumbar pedicle subtraction osteotomy level on lordosis distribution and shape","volume":"29","author":"Pizones","year":"2020","unstructured":"Pizones JMoreno-Manzanaro LPerez-Grueso FJSEffect of lumbar pedicle subtraction osteotomy level on lordosis distribution and shape. Eur Spine J. 2020;29(6):1388-1396."},{"issue":"2","key":"bib1","series-title":"Neurosurg Clin N Am","first-page":"289","article-title":"Flatback syndrome","volume":"18","author":"Lu","year":"2007","unstructured":"Lu DCChou D.Flatback syndrome. Neurosurg Clin N Am. 2007;18(2):289-294."},{"issue":"7","key":"bib2","series-title":"J Bone Joint Surg Am","first-page":"1053","article-title":"Late neurological complications of Harrington-rod instrumentation","volume":"71","author":"Hales","year":"1989","unstructured":"Hales DDDawson EGDelamarter R.Late neurological complications of Harrington-rod instrumentation. J Bone Joint Surg Am. 1989;71(7):1053-1057."},{"issue":"6","key":"bib3","series-title":"J Korean Neurosurg Soc","first-page":"615","article-title":"Surgical outcomes of post-fusion lumbar flatback deformity with sagittal imbalance","volume":"59","author":"Kim","year":"2016","unstructured":"Kim JSKim SM.Surgical outcomes of post-fusion lumbar flatback deformity with sagittal imbalance. J Korean Neurosurg Soc. 2016;59(6):615-621."},{"issue":"4","key":"bib4","series-title":"J Bone Joint Surg Am","first-page":"569","article-title":"Treatment of symptomatic flatback after spinal fusion","volume":"70","author":"Lagrone","year":"1988","unstructured":"Lagrone MOBradford DSMoe JHLonstein JEWinter RBOgilvie JW.Treatment of symptomatic flatback after spinal fusion. J Bone Joint Surg Am. 1988;70(4):569-580."},{"issue":"1","key":"bib5","series-title":"Spine (Phila Pa 1976)","first-page":"62","article-title":"Defining spino-pelvic alignment thresholds: should operative goals in adult spinal deformity surgery account for age?","volume":"41","author":"Lafage","year":"2016","unstructured":"Lafage RSchwab FChallier VDefining spino-pelvic alignment thresholds: should operative goals in adult spinal deformity surgery account for age? Spine (Phila Pa 1976). 2016;41(1):62-68."},{"issue":"2","key":"bib6","series-title":"Radiology","first-page":"341","article-title":"Spinal vacuum phenomena: anatomical study and review","volume":"139","author":"Resnick","year":"1981","unstructured":"Resnick DNiwayama GGuerra JJrVint VUsselman J.Spinal vacuum phenomena: anatomical study and review. Radiology. 1981;139(2):341-348."},{"issue":"2","key":"bib7","series-title":"Neurosurg Focus","first-page":"E15","article-title":"Correction of severe spinopelvic mismatch: decreased blood loss with lateral hyperlordotic interbody grafts as compared with pedicle subtraction osteotomy","volume":"43","author":"Leveque","year":"2017","unstructured":"Leveque JCYanamadala VBuchlak QDSethi RK.Correction of severe spinopelvic mismatch: decreased blood loss with lateral hyperlordotic interbody grafts as compared with pedicle subtraction osteotomy. Neurosurg Focus. 2017;43(2):E15."},{"issue":"1","key":"bib8","series-title":"J Neurosurg Spine","first-page":"56","article-title":"Pedicle subtraction osteotomy: a comprehensive analysis in 104 patients. Does the cause of deformity influence the outcome?","volume":"27","author":"Eskilsson","year":"2017","unstructured":"Eskilsson KSharma DJohansson CHedlund R.Pedicle subtraction osteotomy: a comprehensive analysis in 104 patients. Does the cause of deformity influence the outcome? J Neurosurg Spine. 2017;27(1):56-62."},{"issue":"6","key":"bib9","series-title":"Spine Deform","first-page":"656","article-title":"Complications of posterior column osteotomies in the pediatric spinal deformity patient","volume":"6","author":"Sze","year":"2018","unstructured":"Sze CHSmith JCLuhmann SJ.Complications of posterior column osteotomies in the pediatric spinal deformity patient. Spine Deform. 2018;6(6):656-661."},{"issue":"4","key":"bib10","series-title":"Glob Spine J","first-page":"654","article-title":"Revision strategies for Harrington Rod instrumentation: radiographic outcomes and complications","volume":"12","author":"Louie","year":"2022","unstructured":"Louie PKIyer SKhanna KRevision strategies for Harrington Rod instrumentation: radiographic outcomes and complications. Glob Spine J. 2022;12(4):654-662."},{"key":"bib11","series-title":"Stud Health Technol Inform","first-page":"306","article-title":"Efficacy of posterior only approach for complex iatrogenic flat back","volume":"280","author":"Martikos","year":"2021","unstructured":"Martikos KVommaro FBoriani LScarale AZarantonello PGreggi T.Efficacy of posterior only approach for complex iatrogenic flat back. Stud Health Technol Inform. 2021;280:306."},{"issue":"3","key":"bib12","series-title":"Curr Rev Musculoskelet Med","first-page":"305","article-title":"Lateral and oblique lumbar interbody fusion-current concepts and a review of recent literature","volume":"12","author":"Hah","year":"2019","unstructured":"Hah RKang HP.Lateral and oblique lumbar interbody fusion-current concepts and a review of recent literature. Curr Rev Musculoskelet Med. 2019;12(3):305-310."},{"issue":"suppl 5","key":"bib13","series-title":"Eur Spine J","first-page":"578","article-title":"Sagittal parameters of the spine: biomechanical approach","volume":"20","author":"Roussouly","year":"2011","unstructured":"Roussouly PPinheiro-Franco JL.Sagittal parameters of the spine: biomechanical approach. Eur Spine J. 2011;20(suppl 5):578-585."},{"issue":"6","key":"bib14","series-title":"Neurosurg Focus","first-page":"E5","article-title":"Relative lumbar lordosis and lordosis distribution index: individualized pelvic incidence-based proportional parameters that quantify lumbar lordosis more precisely than the concept of pelvic incidence minus lumbar lordosis","volume":"43","author":"Yilgor","year":"2017","unstructured":"Yilgor CSogunmez NYavuz YRelative lumbar lordosis and lordosis distribution index: individualized pelvic incidence-based proportional parameters that quantify lumbar lordosis more precisely than the concept of pelvic incidence minus lumbar lordosis. Neurosurg Focus. 2017;43(6):E5."},{"issue":"9","key":"bib15","series-title":"Clin Spine Surg","first-page":"E466","article-title":"Correlation between postoperative distribution of lordosis and reciprocal progression of thoracic kyphosis and occurrence of proximal junctional kyphosis following surgery for adult spinal deformity","volume":"31","author":"Ohba","year":"2018","unstructured":"Ohba TEbata SOba HKoyama KHaro H.Correlation between postoperative distribution of lordosis and reciprocal progression of thoracic kyphosis and occurrence of proximal junctional kyphosis following surgery for adult spinal deformity. Clin Spine Surg. 2018;31(9):E466-E472."},{"issue":"4","key":"bib16","series-title":"Neurospine","first-page":"1091","article-title":"New insights into risk factors for proximal junctional failure in adult spinal deformity surgery\u2014a commentary on \u201cproximal junctional failure development despite achieving ideal sagittal correction according to age-adjusted alignment target in patients with adult spinal deformity: risk factor analysis of 196 cases undergoing low thoracic to pelvic fusion","volume":"21","author":"Miyagi","year":"2024","unstructured":"Miyagi MInoue GTakaso M.New insights into risk factors for proximal junctional failure in adult spinal deformity surgery\u2014a commentary on \u201cproximal junctional failure development despite achieving ideal sagittal correction according to age-adjusted alignment target in patients with adult spinal deformity: risk factor analysis of 196 cases undergoing low thoracic to pelvic fusion.\u201d Neurospine. 2024;21(4):1091-1093."},{"issue":"3","key":"bib17","series-title":"Neurospine","first-page":"543","article-title":"Lordosis distribution index in short-segment lumbar spine fusion\u2014can ideal lordosis reduce revision surgery and iatrogenic deformity?","volume":"18","author":"Bari","year":"2021","unstructured":"Bari TJHeegaard MBech-Azeddine RDahl BGehrchen M.Lordosis distribution index in short-segment lumbar spine fusion\u2014can ideal lordosis reduce revision surgery and iatrogenic deformity? Neurospine. 2021;18(3):543-553."},{"issue":"6","key":"bib18","series-title":"Eur Spine J","first-page":"1388","article-title":"Effect of lumbar pedicle subtraction osteotomy level on lordosis distribution and shape","volume":"29","author":"Pizones","year":"2020","unstructured":"Pizones JMoreno-Manzanaro LPerez-Grueso FJSEffect of lumbar pedicle subtraction osteotomy level on lordosis distribution and shape. 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