"Just decompress and fuse" is no longer acceptable in short-segment lumbar surgery. Every fusion - even a single level - shapes your patient's future. Get the sagittal alignment wrong, and you're not just failing to solve the problem - you're creating the next one. Philip Louie sparked this crucial conversation two years ago, challenging the spine community to rethink their approach to sagittal alignment in short-segment fusions. The responses from leading surgeons were illuminating: Peter B. Derman, MD, MBA challenged convention: forget complex formulas, target 45 degrees L4-S1. Direct. Measurable. Effective. Alan H. Daniels, MD and Bassel George Diebo, MD warned against the "more is better" mindset. Just because we can add lordosis in the upper lumbar spine doesn't mean we should - a warning particularly relevant as prone lateral approaches gain popularity. Greg Poulter shared the sobering reality: over a quarter of routine fusions end up out of balance. Most return to theatre within 4 years. Yet in 2024, we still see surgeons compromising on alignment. Still accepting "adequate" when precision is possible. Still using techniques that prioritise ease over outcomes. The technology exists. The knowledge exists. The evidence is clear. The only question is: are we ready to demand better? To every spine surgeon who refuses to compromise: what's holding you back? What needs to change for precise alignment to become the standard, not the exception? Thank you 🙏 , Philip Louie, for starting this vital discussion. Now it's time to take action. Join the conversation. Challenge the status quo. Help us understand why this fundamental aspect of spine surgery remains such a challenge. #SpineSurgery #SurgicalPrecision #SpinalAlignment #PatientOutcomes
Orthopaedic Spine Surgeon and Medical Director of Research and Academics at the Center for Neurosciences and Spine at Virginia Mason Franciscan Health; Co-Founder of STREAMD
*Sagittal Alignment in Degenerative Lumbar Short Segment Fusions* In our recent Spine Journal Club, we had a lively discussion on sagittal alignment planning for short segment lumbar fusions for degenerative pathology. The field of adult spinal deformity surgery has undergone a shift over the last decade, moving from the correction of primarily coronal plane abnormalities to a focus on the sagittal plane (ie. “Flatbacks”) and its association with patient outcomes. The impact of sagittal alignment in short-segment fusions performed on patients presenting with degenerative pathology is less robust than that for long-segment deformity corrections, but recent publications suggest a reduction in adjacent segment degeneration and the subsequent need for repeat surgical procedures in patients with “matched spinopelvic parameters.” For years, the goal of these short segment fusions was to obtain an adequate decompression and stabilization. These goals are important, however, many of us have seen the ramifications to the adjacent segments with fusions performed with “inadequate” restoration (or maintenance) of the segmental lordosis. So, WHAT IS THE GOAL? And how do we achieve these sagittal alignment goals? The discussion was fun because we realized that although our practice places a heavy emphasis on restoring sagittal alignment in this patient population, we our methods of planning differ. I still like to evaluate a PI-LL mismatch goal of less than 10 degrees as a broad goal (within limits). But, others utilize principles of normalized segmental angles and various other methods. Many others do not actively evaluate for sagittal alignment correction/restoration/maintenance in surgery. **What goals plan your sagittal alignment planning in short-segment lumbar fusions?** **Or for the non-surgeons, how have you commonly seen it done?** **Do you utilize a program or measure yourself?** [Alphatec Spine, DePuy Synthes, Medtronic, MiRus LLC, NuVasive, SeaSpine, Surgalign] Alan H. Daniels, MD Bryce Basques, MD Raj Nangunoori Peter B. Derman, MD, MBA Alexander Satin, MD Chester Donnally III, MD Vadim Goz