Radiological and complication outcomes of posterior pedicle subtraction osteotomy compared with anterior column...

Adult spinal deformity (ASD) causes significant functional disability and pain, often necessitating surgical correction to restore sagittal balance. Posterior pedicle subtraction osteotomy (PSO) and anterior column realignment (ACR) represent two powerful but distinct strategies for sagittal correction. While PSO provides robust correction through a posterior approach, it is associated with high morbidity. ACR, performed through a minimally invasive lateral approach, offers comparable angular correction with potentially reduced blood loss and shorter recovery. This meta-analysis aimed to compare radiographic and complication outcomes between PSO and ACR in ASD surgery.

Following PRISMA guidelines, a systematic search was conducted in PubMed, Scopus, Web of Science, and Embase up to October 2025. Eligible studies directly compared ACR and PSO in adult sagittal deformity and reported postoperative lumbar lordosis or complication rates. Data were pooled using random-effects models. Continuous variables were expressed as standardized mean differences (SMDs) and dichotomous outcomes as risk ratios (RRs) with 95 % confidence intervals (CIs).

Five studies (three clinical, two biomechanical) published between 2017 and 2024 met the inclusion criteria. The pooled analysis of lumbar lordosis demonstrated a significant improvement favoring ACR (SMD = 0.68, 95 % CI 0.21-1.15; p = 0.004), with substantial heterogeneity (I² = 82 %). The combined analysis of all complications revealed no significant difference between ACR and PSO (RR = 0.73, 95 % CI 0.46-1.16; p = 0.14; I² = 0 %). Among specific complications, neurologic (RR = 2.12, p = 0.20), vascular (RR = 1.97, p = 0.24), infection (RR = 0.32, p = 0.14), and mechanical (RR = 0.15, p = 0.20) risks were comparable. The rate of unplanned reoperation was significantly lower following ACR (RR = 0.18, 95 % CI 0.03-0.91; p = 0.04).

Both PSO and ACR achieve meaningful sagittal correction in ASD. ACR provides equivalent or superior lordosis restoration with markedly lower intraoperative blood loss and fewer reoperations, supporting its role as a less invasive alternative to PSO in selected patients.