• Pedro Berjano and Max Aebi.
• IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
• Eur Spine J. 2015 Jan 1; 24 Suppl 1: S49-57.

IntroductionThe narrow correlation between sagittal alignment parameters and clinical outcomes has been widely established, demonstrating that improper sagittal alignment is a clinical condition that is associated with increased pain and limitations in patients' functional ability.IndicationLumbar pedicle subtraction osteotomy (PSO) is indicated in the treatment of large sagittal (more than 25° of rigid loss of lordosis) deformities of the lumbar spine or its combination with coronal deformity, especially when they are rigid. Indication should be based on careful assessment of the severity of symptoms, functional impairment, functional expectations of the patient, general clinical condition and surgical and anesthesiological team experience. Risk should be carefully assessed and discussed to obtain appropriate informed consent.Surgical ProcedureSurgical planning includes selection of the safest levels for the upper and lower instrumented vertebra, site of the osteotomy, modality of fixation, and, most importantly angular value of the correction goal (target lumbar lordosis). Failure to adequately obtain the necessary amount of sagittal correction is the most frequent cause of failure and reoperation.ConclusionPSO is a valuable surgical procedure in correction of severe hypolordosis (=relative kyphosis) in the lumbar spine. It is a demanding procedure for the surgeon, the anesthesiologist and the intensive care team. Although its complication rate is high, it has a substantial positive impact in the quality of life of patients, including the elderly.

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