Differences in evaluation and management coding of outpatient clinic visits for patients undergoing elective spine surgery with use of a standardized template.

Background: In a large teaching institution with providers of various levels of training and backgrounds, and a coding department responsible for all evaluation and management (E&M) billing, variations in documentation can hinder accurate medical management and compensation. The purpose of this study is to assess differences in re-imbursement between templated and non-templated outpatient documentation for patients who eventually underwent single level lumbar microdiscectomy and anterior cervical discectomy and fusion (ACDF) both before and after the E&M billing changes were implemented in 2021. Methods: Data was collected from three spine surgeons on 41 patients who underwent a single level lumbar microdiscectomy at a tertiary care center from July 2018 to June 2019 and 35 patients seen by four spine surgeons from January through December of 2021 given the new E&M billing changes. ACDF data was collected for 52 patients between 2018 and 2019 for three spine surgeons and 30 patients from January through December of 2021 from four spine surgeons. Billing level was decided by independent coders for preoperative visits. Results: During the study period from 2018-2019 for lumbar microdiscectomy, each surgeon averaged about 14 patients. Results showed variability of billing level between the three spine surgeons (surgeon 1, 3.2±0.4; surgeon 2, 3.5±0.6; and surgeon 3, 2.9±0.8). Interestingly, even after the implementation of the 2021 E&M billing changes, there was a statistically significant increased level of billing for templated notes for lumbar microdiscectomy (P=0.013). However, this did not translate to the clinic visits for patients who underwent ACDF in 2021. When data was aggregated for all the patients from 2021 who either underwent lumbar microdiscectomy or ACDF, using a template still resulted in a statistically significant higher level of billing (P<0.05). Conclusions: Utilization of templates for clinical documentation reduces variability in billing codes. This impacts subsequent reimbursements and potentially prevents significant financial losses at large tertiary care facilities.

Lumbar spine intervertebral disc desiccation is associated with medical comorbidities linked to systemic inflammation.

INTRODUCTION: Symptomatic disc degeneration is a common cause of low back pain. Recently, the prevalence of low back pain has swiftly risen leading to increased patient disability and loss of work. The increase in back pain also coincides with a rapid rise in patient medical comorbidities. However, a comprehensive study evaluating a link between patient's medical comorbidities and their influence on lumbar intervertebral disc morphology is lacking in the literature. METHODS: Electronic medical records (EMR) were retrospectively reviewed to determine patient-specific medical characteristics. Magnetic resonance imaging (MRI) was evaluated for lumbar spine intervertebral disc desiccation and height loss according to the Griffith-modified Pfirrmann grading system. Bivariate and multivariable linear regression analyses assessed strength of associations between patient characteristics and lumbar spine Pfirrmann grade severity (Pfirrmann grade of the most affected lumbar spine intervertebral disc) and cumulative grades (summed Pfirrmann grades for all lumbar spine intervertebral discs). RESULTS: In total, 605 patients (304 diabetics and 301 non-diabetics) met inclusion criteria. Bivariate analysis identified older age, diabetes, American Society of Anesthesiologists (ASA) class, hypertension, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, and hypothyroidism as being strongly associated with an increasing cumulative Pfirrmann grades. Multivariable models similarly found an association linking increased cumulative Pfirrmann grades with diabetes, hypothyroidism, and hypertension, while additionally identifying non-white race, heart disease, and previous lumbar surgery. Chronic pain, depression, and obstructive sleep apnea (OSA) were associated with increased Pfirrmann grades at the most affected level without an increase in cumulative Pfirrmann scores. Glucose control was not associated with increasing severity or cumulative Pfirrmann scores. CONCLUSION: These findings provide specific targets for future studies to elucidate key mechanisms by which patient-specific medical characteristics contribute to the development and progression of lumbar spine disc desiccation and height loss. LEVEL OF EVIDENCE: III (retrospective cohort).

Effects of Caffeine on Intervertebral Disc Cell Viability in a Whole Organ Culture Model.

STUDY DESIGN: Controlled laboratory study. OBJECTIVE: To investigate the impact of exposure to physiologically relevant caffeine concentrations on intervertebral disc (IVD) cell viability and extracellular matrix composition (ECM) in a whole organ culture model as potential contributing mechanisms in development and progression of IVD disorders in humans. Primary outcome measures were IVD viable cell density (VCD) and ECM composition. METHODS: A total of 190 IVD whole organ explants from tails of 16 skeletally mature rats-consisting of cranial body half, endplate, IVD, endplate, and caudal body half-were harvested. IVD explants were randomly assigned to 1 of 2 groups: uninjured (n = 90) or injured (20G needle disc puncture/aspiration method, n = 100). Explants from each group were randomly assigned to 1 of 3 treatment groups: low caffeine (LCAF: 5 mg/L), moderate caffeine (MCAF: 10 mg/L), and high caffeine (HCAF: 15 mg/L) concentrations. RESULTS: Cell viability was significantly higher in the low-caffeine group compared with the high-caffeine group at day 7 (P = .037) and in the low-caffeine group compared with the medium- and high-caffeine groups at day 21 (P ≤ .004). Analysis of ECM showed that all uninjured and control groups had significantly higher (P < .05) glycosaminoglycan concentrations compared with all injured groups. Furthermore, we observed a temporal, downward trend in proteoglycan to collagen ratio for the caffeine groups. CONCLUSIONS: Caffeine intake may be a risk factor for IVD degeneration, especially in conjunction with disc injury. Mechanisms for caffeine associated disc degeneration may involve cell and ECM, and further studies should elucidate mechanistic pathways and potential benefits for caffeine restriction.

Surgical Reduction of Spondylolisthesis During Lumbar Fusion: Are Complications Associated With Slip Correction?

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The objective of this study was to quantify the rates of complication following surgical treatment for symptomatic degenerative and isthmic spondylolisthesis and to examine the association between slip reduction and complication rates. SUMMARY OF BACKGROUND DATA: It is unclear if the degree of spondylolisthesis reduction during lumbar spine fusion in adults influences the rate of surgical complications. METHODS: This is a retrospective cohort study of 1-level and 2-level adult fusion patients with degenerative or isthmic spondylolisthesis. The degree of reduction and complications were calculated, and complication rates between those with and without reduction were compared. RESULTS: The surgical reduction was improved by 1 Meyerding grade in 56.5% of the 140 patients included in this analysis. Of those patients, 60% had a grade 1 spondylolisthesis. In addition, 62.5% of grade 2 slips had an improvement by 1 grade. Surgical reduction during lumbar fusion did not result in a higher rate of complications compared with in situ fusion. CONCLUSIONS: During 1-level or 2-level lumbar fusion for degenerative or isthmic spondylolisthesis, a 1-grade reduction of the slip was achieved in 56% of patients in this retrospective case series. Reduction of the spondylolisthesis was not associated with a higher rate of complication when compared with in situ fusion. LEVEL OF EVIDENCE: Level IV.

Is It Cost Effective to Obtain Fungal and Acid-Fast Bacillus Cultures during Spine Debridement?

STUDY DESIGN: Retrospective study. PURPOSE: To identify the rate of positive acid-fast bacillus (AFB) and fungal cultures during spine debridement, determine whether these infections are more common in certain spine segments, identify comorbidities associated with these infections, and determine whether the universal performance of fungal and AFB cultures during spine debridement is cost effective. OVERVIEW OF LITERATURE: Spine infections are associated with significant morbidity and costs. Spine fungal and AFB infections are rare, but their incidence has not been well documented. As such, guidance regarding sample procurement for AFB and fungal cultures is lacking. METHODS: A retrospective review of medical record data from patients undergoing spine irrigation and debridement (I&D) at the University of Missouri over a 10-year period was performed. RESULTS: For patients undergoing spine I&D, there was a 4% incidence of fungal infection and 0.49% rate of AFB infection. Steroid use was associated with a higher likelihood (odds ratio, 5.62; 95% confidence interval, 1.33-23.75) of positive fungal or AFB cultures. Although not significant, patients undergoing multiple I&D procedures had higher rates of positive fungal cultures during each subsequent I&D. Over a 10-year period, if fungal cultures are obtained for each patient, it would cost our healthcare system $12,151.58. This is compared to an average cost of $177,297.64 per missed fungal infection requiring subsequent treatment. CONCLUSIONS: Spine fungal infections occur infrequently at a rate of 4%. Physicians should strongly consider obtaining samples for fungal cultures in patients undergoing spine I&D, especially those using steroids and those undergoing multiple I&Ds. Our AFB culture rates mirror the false positive rates seen in previous orthopedic literature. It is unlikely to be cost effective to send for AFB cultures in areas with low endemic rates of AFB.

Comorbidities associated with cervical spine degenerative disc disease.

Determining important links between medical comorbidities and cervical spine degenerative disc disease (DDD) will help elucidate pathomechanisms of disc degeneration. Electronic medical records and magnetic resonance imaging were retrospectively reviewed to evaluate 799 patients assessed for cervical spine pathology. Bivariate analysis identified older age, diabetes, ASA class, cancer, COPD, depression, hypertension, hypothyroidism, Medicare status, peripheral vascular disease, history of previous cervical spine surgery, smoking, and lower median household income as having strong associations with increased cumulative grade of cervical spine DDD. This study provides evidence suggesting aging and accumulation of medical comorbidities influence severity of cervical spine DDD.

Orthopedic Manifestations of Cystic Fibrosis.

Cystic fibrosis (CF) is a relatively common disease seen in Whites of northern European descent. Classically, it was a lethal disease and uncommon for the orthopedic practitioner to interact with CF patients. Recent pharmaceutical breakthroughs targeting the CF transmembrane conductance regulator (CFTR) gene have significantly prolonged patient life expectancy. This makes it increasingly likely that orthopedic surgeons will encounter CF patients in their clinic. In this article, the authors discuss pertinent musculoskeletal manifestations of the CF population, including the increased risk of decreased bone mineral density and bone mineral content, muscle deconditioning, spinal kyphosis, fractures, and elevated systemic inflammation predisposing these individuals to CF-related arthralgia. The diagnoses are grouped into subspecialties (arthroplasty, pediatrics, spine, sports, and trauma) most likely to evaluate the patient. Additionally, the authors review treatment options for these conditions and discuss the need for these patients to be seen in the perioperative period by their CF care team for patient optimization due to their diminished pulmonary function. Interspersed with this literature review, the authors present 2 unique cases. The first case details a patient with pain over her spine due to multilevel spinous process bursitis caused by a high-frequency chest wall oscillation system, which masquerades as an infection. The second case is a non-contact midsubstance rectus femoris tear in an athlete. These cases highlight the need for increased vigilance for uncommon diagnoses in the CF patient population. [Orthopedics. 2021;44(3):e440-e445.].

Responsiveness of routine diagnostic tests for vertebral osteomyelitis may be influenced by the infecting organism.

BACKGROUND CONTEXT: Vertebral osteomyelitis (VO) becomes increasingly more prevalent as people age, and it is a condition seen frequently by referral center spine surgeons. It can take as long as 6 months for a proper diagnosis to be made. Staphylococcus aureus (S. aureus) is the most common isolated organism in up to 80% of the affected population. The clinical presentation of vertebral osteomyelitis is typically non specific (back pain), which can make timely diagnosis challenging. Fever is often absent. Serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell count (WBC) and serum polymorphonuclear leukocyte percentage (PMN%) are traditionally used as first-line tests because of their perceived sensitivity to help diagnose vertebral osteomyelitis. It is not known whether these test values are affected by the infecting organism. PURPOSE: To determine whether individual first-line diagnostics differed based on infecting organism and whether certain organisms are associated with lower lab values. Additionally, this study sought to determine if VO caused by lower virulent (eg, culture-negative and nonpyogenic organisms) could contribute to delays in treatment due to lack of elevated biomarkers. STUDY DESIGN/SETTING: Single-center retrospective cohort study. PATIENT SAMPLE: We reviewed clinical data of 133 patients (60% male) diagnosed with VO from 2015-2019 in a US Midwest academic hospital. OUTCOMES MEASURES: Primary outcome measures included the maximum temperature upon presentation, serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell count (WBC), and percentage neutrophils during the hospital admission. METHODS: Inclusion criteria were adult patients diagnosed with vertebral osteomyelitis who underwent blood culture and/or biopsy prior to treatment. All patients enrolled in the study were diagnosed with VO and confirmed via magnetic resonance imaging (MRI). MRI findings associated with VO included destruction of endplates, increased signal in vertebral bodies, and the surrounding disc on T2-weighted imaging were confirmed. The patients had laboratory work up and clinical follow up regardless of positive culture or negative culture. The mean peak inflammatory marker levels were compared among organisms with student's t test. Demographics, comorbidities, and CCI were collected and multivariable logistic regression models were used. Receiver operating characteristic curve analysis was performed to delineate separate, optimal cut offs for CRP, ESR, WBC, and PMN% for patients with culture positive osteomyelitis RESULTS: Patients' average age was 57.0±13.7 years with a mean BMI of 30.5±9.70 kg/m2, and a mean Charleston Comorbidity Index (CCI) of 3.17±2.35. Staphylococcus aureus and antibiotic resistant organisms (MRSA and VRE) demonstrated a higher mean CRP and ESR than culture negative, fungal and TB cases. Staphylococcus aureus, antibiotic resistant organisms, and coagulase negative Staphylococcus demonstrated a higher mean WBC than culture negative as well as fungal and TB cases. Staphylococcus aureus, antibiotic resistant organisms, coagulase negative Staphylococcus, and Streptococcus species had a higher mean peak PMN%, than culture negative as well as fungal and TB case. Temperature did not correlate with a diagnosis of osteomyelitis. CONCLUSIONS: Serum laboratory markers in the diagnosis of VO appear to be influenced by the infecting organism type. Laboratory values in patients diagnosed with VO with culture negative or non-pyogenic organisms are lower compared to antibiotic resistant and S. aureus organisms. Fever did not correlate with a diagnosis of VO.

Comparison of recovery after sugammadex or neostigmine reversal of rocuronium in geriatric patients undergoing spine surgery: a randomized controlled trial.

AIM: To evaluate the effect of sugammadex compared with neostigmine on speed and quality of recovery after rocuronium neuromuscular blockade (NMB) in geriatric patients undergoing posterior lumbar spine surgery. METHODS: This randomized controlled study at a tertiary academic medical center involved 40 patients (age ≥65 years, ASA PS II/III) scheduled for elective surgery under general anesthesia. Patients were randomized to sugammadex or neostigmine for reversal of moderate NMB with rocuronium. The primary outcome was recovery time from NMB after surgery to a train-of-four (TOF) ratio ≥0.9 measured at the adductor pollicis (TOF-Watch® SX). Secondary outcomes included hemodynamic change after administration of reversal agent (heart rate, blood pressure, dysrhythmia), time to extubation, pain medication requirement, time to first ambulation, and length of postanesthesia care unit (PACU) and total hospital stay. RESULTS: Sugammadex (4±2.2 min) compared with neostigmine reversal (26.3±17.5 min) was on average 22 min faster (95% CI 14.1-30.5; P≤0.001) with less variability (range 2-11 min vs 5-72 min). The groups significantly differed in time for tracheal extubation, response to verbal commands (open eyes, squeeze hand, lift head), and operating room exit. However, they had similar PACU stay, time to first ambulation, total hospital stay, postoperative pain, and opioid use. Sugammadex had less hemodynamic variability than neostigmine. No patient developed treatment-emergent dysrhythmias. CONCLUSION: Sugammadex reversal significantly hastened NMB recovery compared with neostigmine reversal in geriatric patients. It significantly decreased operating room time but not PACU time or hospital stay.

Canine models of spine disorders.

Neck and low back pain are common among the adult human population and impose large social and economic burdens on health care and quality of life. Spine-related disorders are also significant health concerns for canine companions with etiopathogeneses, clinical presentations, and diagnostic and therapeutic options that are very similar to their human counterparts. Historically, induced and spontaneous pathology in laboratory rodents, dogs, sheep, goats, pigs, and nonhuman primates have been used for study of human spine disorders. While each of these can serve as useful preclinical models, they all have inherent limitations. Spontaneously occurring spine disorders in dogs provide highly translatable data that overcome many of the limitations of other models and have the added benefit of contributing to veterinary healthcare as well. For this scoping review, peer-reviewed manuscripts were selected from PubMed and Google Scholar searches using keywords: "intervertebral disc," "intervertebral disc degeneration," "biomarkers," "histopathology," "canine," and "mechanism." Additional keywords such as "injury," "induced model," and "nucleus degeneration" were used to further narrow inclusion. The objectives of this review were to (a) outline similarities in key features of spine disorders between dogs and humans; (b) describe relevant canine models; and (c) highlight the applicability of these models for advancing translational research and clinical application for mechanisms of disease, diagnosis, prognosis, prevention, and treatment, with a focus on intervertebral disc degeneration. Best current evidence suggests that dogs share important anatomical, physiological, histological, and molecular components of spinal disorders in humans, such that induced and spontaneous canine models can be very effective for translational research. Taken together, the peer-reviewed literature supports numerous advantages for use of canine models for study of disorders of the spine when the potential limitations and challenges are addressed.

The minipig as a potential model for pedicle screw fixation: morphometry and mechanics.

BACKGROUND: While there are several different animal models for use in the characterization of spinal fixation, none have emerged as a definitive model for comparative studies in spinal fixation methods. The purpose of this study is to establish morphometric data of porcine vertebrae and to characterize the feasibility of pedicle screw fixation in porcine spines for potential comparative human study. METHODS: Four spines from 45 to 50 kg Hanford minipigs were cleaned of soft tissue and analyzed by computed tomography and dual-energy x-ray absorptiometry. Two 5 × 30-mm pedicle screws were placed in each vertebra and tested to failure using a combined moment-load protocol. RESULTS: Pedicle widths were measured from L6-T5. Widths ranged from 7.15 mm (T6) to 9.24 mm (T14). Posterior cortex to anterior cortex depth ranged from 25.9 to 32.6 mm. Mean bone mineral density was 1.0665 g/cm2 (range 1.139-1.016). Force-to-failure demonstrated mean 1171.40 N (+ 115.34). CONCLUSION: Our baseline morphometric and compositional data demonstrate that porcine vertebrae can serve as a useful model for comparative studies due to their similar pedicle widths and bone mineral density to the human vertebra. This biomechanical data could provide a baseline comparison for future studies. This study also suggests that the minipig could be a suitable model for comparative studies due to similarities in pedicle width and bone mineral density to the human vertebrae.

Dispersal Pattern of Injectate After Cervical Epidural Steroid Injection Evaluated With Magnetic Resonance Imaging.

STUDY DESIGN: Prospective, nonrandomized, clinical study. OBJECTIVE: Epidural steroid injections (ESIs) are an important diagnostic and treatment modality for spine pathology. The success of these injections has been attributed to the anatomic location reached by the injectate. This study evaluates injectate dispersal patterns after cervical interlaminar ESI using magnetic resonance imaging (MRI). METHODS: Patients between the ages of 18 and 85 years with cervical radiculopathy were identified. After obtaining consent for study participation, a gadolinium-enhanced cervical ESI was administered via an interlaminar approach under fluoroscopic guidance. Study participants underwent a cervical spine MRI within 15 minutes of administering the injection. Craniocaudal dispersal and the presence or absence of circumferential dispersal was assessed. RESULTS: The injectate dispersed a mean of 8.11 cm in the cranial direction, 6.63 cm in the caudal direction, and 360° circumferentially. No adverse events related to the ESI were reported. CONCLUSIONS: Fluoroscopy-guided cervical interlaminar ESI resulted in nearly uniform circumferential dispersal within the epidural space with multilevel migration in the cranial and caudal directions. MRI is a safe and accurate tool to evaluate spinal injectate dispersal.

The Importance of Determining Trainee Perspectives on Procedural Competencies During Spine Surgery Clinical Fellowship.

STUDY DESIGN: Longitudinal survey. OBJECTIVE: It remains important to align competence-based objectives for training as deemed important by clinical fellows to those of their fellowship supervisors and program educators. The primary aim of this study was to determine trainee views on the relative importance of specific procedural training competencies. Secondarily, we aimed to evaluate self-perceived confidence in procedural performance at the commencement and completion of fellowship. METHODS: Questionnaires were administered to 68 clinical fellows enrolled in the AOSNA fellowship program during the 2015-2016 academic year. A Likert-type scale was used to quantify trainee perspectives on the relative importance of specific procedural competencies to their training base on an established curriculum including 53 general and 22 focused/advanced procedural competencies. We measured trainee self-perceived confidence in performing procedures at the commencement and completion of their program. Statistical analysis was performed on fellow demographic data and procedural responses. RESULTS: Our initial survey response rate was 82% (56/68) and 69% (47/68) for the follow-up survey. Although most procedural competencies were regarded of high importance, we did identify several procedures of high importance yet low confidence among fellows (ie, upper cervical, thoracic discectomy surgery), which highlights an educational opportunity. Overall procedural confidence increased from an average Likert score of 4.2 (SD = 1.3) on the initial survey to 5.4 (SD = 0.8) by follow-up survey (P < .0001). CONCLUSIONS: Understanding trainee goals for clinical fellowship remains important. Identification of areas of low procedural confidence and high importance to training experience will better guide fellowship programs and supervisors in the strategic delivery of the educational experience.

Surgical Site Infection in Spine Surgery: Who Is at Risk?

STUDY DESIGN: Retrospective literature review of spine surgical site infection (SSI). OBJECTIVE: To perform a review of SSI risk factors and more specifically, categorize them into patient and surgical factors. METHODS: A review of published literature on SSI risk factors in adult spine surgery was performed. We included studies that reported risk factors for SSI in adult spinal surgery. Excluded are pediatric patient populations, systematic reviews, and meta-analyses. Overall, we identified 72 cohort studies, 1 controlled-cohort study, 1 matched-cohort study, 1 matched-paired cohort study, 12 case-controlled studies (CCS), 6 case series, and 1 cross-sectional study. RESULTS: Patient-associated risk factors-diabetes mellitus, obesity (body mass index >35 kg/m2), subcutaneous fat thickness, multiple medical comorbidities, current smoker, and malnutrition were associated with SSI. Surgical associated factors-preoperative radiation/postoperative blood transfusion, combined anterior/posterior approach, surgical invasiveness, or levels of instrumentation were associated with increased SSI. There is mixed evidence of age, duration of surgery, surgical team, intraoperative blood loss, dural tear, and urinary tract infection/urinary catheter in association with SSI. CONCLUSION: SSIs are associated with many risk factors that can be patient or surgically related. Our review was able to identify important modifiable and nonmodifiable risk factors that can be essential in surgical planning and discussion with patients.

Patient satisfaction in musculoskeletal medicine.

PURPOSE OF REVIEW: This is a literature review of the measurement of patient satisfaction in musculoskeletal medicine. Its purpose is to better understand the motivation for such measurements, the potential confounders, and the potential physician behaviors that may modulate such measures. RECENT FINDINGS: There have been studies documenting that physician conveyance of empathy, the extent to which patients' expectations for pain control and timeliness of care are met, as well as patient demographics and health status all affect the current measures of patient satisfaction. In the mission to affect patient-centered care are met, musculoskeletal providers will be measured by their patients' satisfaction. There is much yet to be understood regarding patients' expectations of care; the science behind case-mix adjustment in this sphere is in its infancy, but there are some compelling reasons for musculoskeletal providers to attempt to optimize their patients' satisfaction.

Emerging Techniques in Degenerative Thoracolumbar Surgery.

There continue to be incremental advances in thoracolumbar spine surgery techniques in attempts to achieve more predictable outcomes, minimize risk of complications, speed recovery, and minimize the costs of these interventions. This paper reviews recent literature with regard to emerging techniques of interest in the surgical treatment of lumbar spinal stenosis, fusion fixation and graft material, degenerative lumbar spondylolisthesis, and thoracolumbar deformity and sacroiliac joint degeneration. There continue to be advances in minimal access options in these areas, although robust outcome data are heterogeneous in its support. The evidence in support of sacroiliac fusion appears to be growing more robust in the properly selected patient.

Treating the Aging Spine.

Demographic trends make it incumbent on orthopaedic spine surgeons to recognize the special challenges involved in caring for older patients with spine pathology. Unique pathologies, such as osteoporosis and degenerative deformities, must be recognized and treated. Recent treatment options and recommendations for the medical optimization of bone health include vitamin D and calcium supplementation, diphosphonates, and teriparatide. Optimizing spinal fixation in elderly patients who have osteoporosis is critical; cement augmentation of pedicle screws is promising. In the management of geriatric odontoid fractures, nonsurgical support with a collar may be considered for low-demand patients, whereas surgical fixation is favored for high-demand patients. Management of degenerative deformity must address sagittal plane balance, which includes consideration of pelvic incidence. Various osteotomies may prove helpful in this setting.