Anterior Column Realignment Plus Smith–Petersen Osteotomy Versus Smith–Petersen Osteotomy-Only for Adult Spinal Deformity

BACKGROUND AND OBJECTIVES: Anterior column realignment (ACR) can increase segmental lordosis through anterior longitudinal ligament release and hyperlordotic cage placement, but its additive value when combined with Smith-Petersen osteotomy (SPO)-based constructs is not fully clear. We compared outcomes of ACR + SPO vs SPO-only in thoracolumbar adult spinal deformity (ASD). METHODS: We performed a retrospective cohort study of adults undergoing multilevel thoracolumbar fusion with pelvic fixation for ASD (2022-2024). All patients had ≥1 SPO and ≥1 instrumented interbody fusion and were grouped by whether ACR was performed (ACR + SPO vs SPO-only). Primary outcomes were changes in Oswestry Disability Index and visual analogue scale (VAS) scores (axial and radicular pain) at ≥6-month follow-up. Secondary outcomes included lumbar lordosis, pelvic tilt, sagittal vertical axis, length of hospital stay, and complications. RESULTS: Sixty-six patients met criteria (ACR + SPO n = 27; SPO-only n = 39). Improvements in Oswestry Disability Index and radicular VAS were clinically meaningful in both cohorts without clear between-group differences. Radiographic alignment improved in both cohorts; lumbar lordosis correction per interbody level was similar (5.7° vs 5.4°). Length of stay was significantly longer with ACR (P-value .003). Residual postoperative axial pain was higher with ACR (VAS mean difference 1.0; P-value .009), and axial pain improvement favored SPO-only (ΔVAS mean difference 1.2; P-value .019). Mechanical complications, proximal junctional complications, major medical events, and reoperation rates were not meaningfully different between groups. CONCLUSION: In thoracolumbar ASD reconstruction built on posterior column osteotomies, ACR did not provide superior correction of global sagittal alignment or greater improvement in disability or radicular pain, but it increased hospitalization and was associated with worse residual axial pain, supporting selective, indication-driven use.