Anterior Column Realignment (ACR): Surgical Technique and Clinical Outcomes

Anterior column realignment (ACR) has emerged as a powerful minimally invasive surgical (MIS) technique for restoring lumbar lordosis and correcting sagittal spinopelvic malalignment in adult spinal deformity (ASD). By releasing the anterior longitudinal ligament and inserting a hyperlordotic interbody cage through a lateral transpsoas approach, ACR enables substantial segmental and global sagittal correction while minimizing the morbidity associated with traditional three-column osteotomies. In addition to deformity correction, ACR facilitates effective indirect neural decompression through restoration of disc height, reduction of disc bulging, and unbuckling of the ligamentum flavum. This chapter reviews the surgical technique of ACR, including patient positioning, transpsoas access, neuromonitoring strategies, anterior longitudinal ligament release, and cage placement. Radiographic and MRI-based analyses demonstrating restoration of lumbar lordosis, improvement of PI–LL mismatch, and expansion of the spinal canal are presented. Clinical outcomes and complication profiles of short-segment MIS combinations incorporating ACR are also discussed, with particular emphasis on junctional complications and the importance of physiological lordosis distribution. Finally, patient selection, biomechanical considerations, and surgical pearls for the safe and effective application of ACR are summarized.