Purpose
Despite the increasing prevalence of spinal deformity correction using lateral lumbar interbody fusion (LLIF) for degenerative adult spinal deformity, the amount of sagittal plane correction is reported to be suboptimal. Thus, authors have performed mini-open anterior lumbar interbody fusion (ALIF) at the most caudal segment in adjunct to LLIF to make sufficient lumbar lordosis (LL). This study is performed to demonstrate the feasibility of mini-open anterior lumbar interbody fusion (ALIF) combined with lateral lumbar interbody fusion (LLIF) followed by 2-stage posterior fixation in terms of the correction capacity and complications by comparing with a matched control group undergoing posterior-only surgery.
Materials and Methods
This study was case-control study. Thirty patients who underwent ALIF with LLIF followed by 2-stage posterior fixation (ALIF/LLIF group) for adult spinal deformity were compared to 60 patients who underwent posterior-only surgery (posterior group) and were matched according to age, sex, diagnosis, fusion length, pelvic incidence (PI), and follow-up duration. Spinopelvic parameters, hospitalization data, clinical outcomes, and complications were evaluated and compared between ALIF/LLIF and posterior groups.
Results
In the ALIF/LLIF group, interbody fusions were performed for a mean of 4.0 levels, comprising 1.6 and 2.4 levels for ALIF and LLIF, respectively. Interbody fusion in the posterior group was performed for a mean of 3.3 levels. The mean follow-up duration did not differ between two groups (16.7 mo vs. 19.2 mo, p=0.056). Postoperative LL was greater in the ALIF/LLIF than in the posterior group (52.0° vs. 40.9°, p<0.001). The reduction in the sagittal vertical axis was also greater for the ALIF/LLIF group than the posterior group (62.3 mm vs. 24.7 mm). The operation time of the ALIF/LLIF group was longer than the posterior group (11.2 hr vs. 8.6 hr, p<0.001), while estimated blood loss and red cell transfusion was less in the ALIF/LLIF group. Medical complications developed more frequently in the posterior group, while perioperative surgical complications were not different between groups. Delayed surgical complications were observed more in the posterior group. In the posterior group, there were 7 patients who experienced nonunion and rod breakage and 10 patients who experienced decompensation, while there were no such cases in the ALIF/LLIF group.
Conclusion
Mini-open ALIF combined with LLIF can restore sagittal balance more appropriately with a lower rate of complications compared with posterior-alone surgery for the correction of ASD.

Purpose
To compare the difference of cervical alignment between cervical lateral radiograph and whole-spine lateral radiograph by the effects of radiographic position and to assess the effect of the shoulder flexed position to cervical lordotic curvature and head position.
Materials and Methods
We retrospectively evaluated 43 asymptomatic adult patients who were taken horizontal gazing standing cervical and whole-spine lateral radiograph simultaneously from Sep. 2008 to Dec. 2009. Cervical lateral radiograph was taken with the arms extended and hand gently clasped on both side and whole-spine lateral radiograph was taken in the position that subject were relaxed standing with fists-on-clavicles position. Cervical sagittal alignment were analyzed the following parameters. (1) Gore angle (GA, C2-7 angle); (2) Cobb angle (CA, C2-7 angle); (3) translation distance (TD, distance of C2 compared with vertical line through the posterior-inferior body of C7); (4) McGregor angle (MA, angle between McGregor line and horizontal line).
Results
The mean of GA and CA in cervical radiograph were -12.64° and -9.96°, whereas -7.12° and -4.98° in wholespine radiograph. The mean TD and MA were in cervical radiograph were 16.95mm and 7.15°, whereas, 14.97mm and 6.54° respectively in whole-spine radiograph.
Conclusion
Our study showed the significant differences of cervical alignment and head position between standing cervical lateral and whole-spine lateral radiograph. The radiographic posture of whole-spine lateral radiograph with horizontal gazing and fists-on-clavicles position make cervical alignment and head position less lordotic and posterior translation compared to cervical radiograph.

Spinal sagittal balance is influenced by thoracic kyphosis, lumbar lordosis, as well as the position and angle of the pelvis. The abnormal position of sagittal imbalance causes easy fatigue and pain on the back muscles, so that the body voluntarily takes action to compensate for the imbalance. Compensatory mechanism occurs over several steps. It begins primarily in the mobile lumbar segments. When sagittal imbalance occurs due to decreased lumbar lordosis, the disc space at the mobile segments is hyperextended, allowing the C7 plumb to be restored within near normal range. As patients are older, subsequent degenerative disc changes develops at the hyperlordotic segments leading to loss of lumbar lordosis, which results in sagittal imbalance again. If the compensation in the spine is no longer able to restore the sagittal imbalance, posterior rotation of pelvis can reestablishes sagittal balance. This finding shows that the rotation of pelvis is important in the compensatory mechanisms. Another thing to consider is that compensation gets involved in the actual lumbar lordosis. During the compensation process rotation of pelvis determines the sagittal imbalance. This is also very difficult to estimate how much the rotation of pelvis is, because the rotation is variable depending on the position. Pelvic incidence (PI) is a suitable index to determine how much correction of lumbar lordosis requires, as this does not change depending on the position of the pelvis. Patients with high PI are able to compensate the sagittal imbalance more than them with low PI. As PI is the sum of pelvic tilt and sacral slope, PI is closely related to lumbar lordosis. Patients with high PI needs more correction of lumbar lordosis to restore sagittal imbalance than the patients with low PI.

In patient with loss of lumbar lordosis, lumbar lordosis restoration is very important to get a normal sagittal balance. It is difficult to know the ideal lumbar lordosis, because it is a individual-unique pattern and is influenced by numerous variables. To restore a more ideal lumbar lordosis, careful analysis and planning will be needed because incomplete restoration of lumbar lordosis may result in poor clinical outcomes and serious complications. Lumbar lordosis has strong relationship with pelvic orientation, so there are many reports about predictive equation of lumbar lordosis using pelvic parameters. Pelvic incidence is major determinant of pelvic orientation, therefore, influence on lumbar lordosis. So pelvic incidence is a useful value to determine the ideal lumbar lordosis, and we recommend that the degree of restoration of lumbar lordosis is just enough to pelvic incidence at least. And also, a close study and understanding of the numerous factors affecting lumbar lordosis was needed to effective lumbar lordosis restoration.