Efficacy of Ponte Osteotomies in the Surgical Treatment of Scheuermann's Disease: An Analysis of Optimal Spinal Levels for Correction

Efficacy of Ponte Osteotomies in the Surgical Treatment of Scheuermann's Disease: An Analysis of Optimal Spinal Levels for Correction | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficacy of Ponte Osteotomies in the Surgical Treatment of Scheuermann's Disease: An Analysis of Optimal Spinal Levels for Correction Luigi Aurelio Nasto, Alessandro Cattolico, Angelo Sieczak, Achille Marciano, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6686863/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Scheuermann's kyphosis is a structural spinal deformity that typically develops before puberty, affecting the thoracic or thoracolumbar spine. Ponte osteotomy is a widely used surgical technique for multiplanar correction of this condition. This study aims to evaluate the radiographic outcomes and effectiveness of Ponte osteotomies in the surgical treatment of Scheuermann’s kyphosis, and to determine the optimal spinal levels for osteotomy to achieve ideal sagittal alignment. Methods: A retrospective review was conducted on 63 patients who underwent Ponte osteotomies combined with posterior spinal fusion for the correction of Scheuermann’s kyphosis between 2018 and 2022. Radiographic parameters including thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), and pelvic incidence–lumbar lordosis mismatch (PI–LL), were measured preoperatively, postoperatively, and at a two-year follow-up. The number and location of Ponte osteotomies were analyzed in relation to the degree of correction achieved. Results: The study included 63 patients (42% male, 58% female), with a mean age of 20.4 years. The mean TK was significantly reduced from 78.52° ± 6.47° preoperatively to 44.67° ± 4.98° postoperatively (p < 0.001), with correction maintained at follow-up. Significant improvements were also observed in lumbar lordosis (LL) and the pelvic incidence–lumbar lordosis mismatch (PI–LL). The greatest angular corrections were achieved at the T9–T10 and T10–T11 levels. Intervertebral disc height analysis revealed consistent anterior disc opening, stable central height, and decreased posterior disc height postoperatively. No statistically significant correlation was found between anterior disc height increase and Cobb angle correction. Conclusion: Ponte osteotomies are effective in achieving and maintaining significant TK correction in patients with Scheuermann’s disease. Optimal sagittal alignment is best achieved by targeting the osteotomies at the apical region and adjacent levels, with a relatively low rate of complications. Scheuermann’s Kyphosis Ponte Osteotomy Spinal Deformity Correction Thoracic Kyphosis Sagittal Alignment Posterior Spinal Fusion Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 1. Introduction Scheuermann's disease, also known as Juvenile Vertebral Osteochondrosis , is the main cause of adolescent hyperkyphosis in the thoracic and thoracolumbar spine [1]. Horgel Welfer Scheuermann defined this disease for the first time in 1920 [2]. It targets the vertebral endplate's growth cartilage, leading to vertebral body wedging, Schmorl's nodes, and disc degeneration. It can cause chronic back pain, neurologic impairment, and cosmetic problems in patients. It is considered one of the most common sagittal angular spinal deformities, with an incidence of 4–8% and no gender discrimination [3]. Although there is no known cause of this deformity, different theories include genetic mutation involving a mutant major gene and candidate genes, altered biomechanics, idiopathic juvenile osteoporosis, and elevated growth hormone levels, with well-documented physiological impacts and physical effects [2,4]. The disease is classified into two types, with the typical form being more prevalent than the atypical one, and it primarily affects the thoracic spine, potentially leading to thoracic hyperkyphosis with lumbar lordosis [5]. Differential diagnosis includes postural kyphosis, sequelae of vertebral compression fracture, curved back, spondyloepiphyseal dysplasia, osteochondral dystrophy, and spondylodiscitis, all of which must be ruled out before proceeding with treatment [6]. Different treatment options include non-surgical and surgical management. Indications for conservative management are thoracic kyphosis (TK) > 50°, or kyphosis > 45° with radiographic stigmata such as Schmorl’s nodes or wedged vertebrae. These include physiotherapy, exercises, anti-inflammatory medications, and orthopedic corsets, and are considered primary management strategies, emphasizing early intervention for best outcomes [7]. Surgery is reserved for adult patients with severe deformity (i.e., kyphosis over 75°), functional disability with severe pain, neurological impairments, cosmetic concerns, cardiothoracic problems (Cobb > 100°), or those not responding to conservative meaures [5,8]. Different surgical approaches include anterior release, posterior approach (even with Patient specific pre-contoured rods (PSRs) and instrumentation[9]), and the combination approach—each with its benefits and drawbacks. The gold standard for correcting this disease was considered apical anterior release and fusion followed by posterior spinal fusion, which was established in 1975 [4]. With the introduction of multi-segmental compression instruments, the trend shifted toward the posterior approach with the introduction of Ponte osteotomy and sagittal subtraction osteotomy. Ponte described the Ponte osteotomy for sagittal kyphosis in 1987 [10]. With advancements in this technique, modern instrumentation, and the use of pedicle screws, it is now widely used for deformities in the coronal, sagittal, and rotational planes, enabling effective correction using a singular posterior approach. Advantages of this technique include a single-staged procedure, no compromise to the anterior blood supply of the spinal cord, increased level of safety, no complications from thoracoscopy or thoracotomy, and minimized exposure of the spinal canal. This method also reduces surgical duration and blood loss compared to the combined approach, which is more invasive and generally reserved for severe deformities [11]. The aim of our study is to evaluate the effectiveness of Ponte osteotomies in treating Scheuermann's disease. We aim to identify specific vertebral levels where osteotomies offer better correction. Additionally, we explore the osteotomies' impact on intervertebral disc opening and whether a relationship exists between the extent of correction and disc space expansion. Insights from this research can guide surgeons in preoperative planning, determining the number of osteotomies, and possibly reducing surgery time and hemorrhagic risk. 2. Methodology This retrospective observational study was conducted at the Orthopedics Department of A.O.U. Luigi Vanvitelli over a four-year period, from 2018 to 2022, to evaluate the efficacy of high-density instrumented posterior spinal fusion combined with Ponte osteotomies in patients with Scheuermann’s kyphosis. Our local ethical committee (Comitato Etico Aziendale) approved the study (Ethical Approval No. 20180001473h), and written informed consent was waived because of retrospective study. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [12]. Patients with a confirmed clinical and radiological diagnosis of Scheuermann’s disease who underwent only posterior surgical correction were included. Segmental correction was assessed by comparing preoperative and postoperative Cobb angles at each vertebral level where a Ponte osteotomy was performed. Additionally, changes in intervertebral disc morphology were evaluated by measuring anterior, middle, and posterior disc heights before surgery, after surgery, and at follow up. For regional analysis, vertebral levels were categorized into three groups: the upper thoracic group (T3–T4, T4–T5, T5–T6), the middle thoracic group (T6–T7, T7–T8, T8–T9), and the lower thoracic group (T9–T10, T10–T11, T11–T12). This stratification allowed for a detailed comparison of the corrective impact across different thoracic regions. Radiographic assessments were performed using standardized anteroposterior and lateral weight-bearing radiographs obtained preoperatively, immediately postoperatively, and at follow-up. All imaging was conducted using consistent protocols by a dedicated radiology team within the same institution, ensuring measurement accuracy and reproducibility. 2.1. Participants The study cohort included 63 patients (42% male and 58% female), aged between 14 and 25 years, with a mean age of 20.42 years. All patients underwent posterior spinal fusion with Ponte osteotomies using high-density instrumentation, performed by a single surgeon with expertise in spinal surgery. Surgical indications were determined based on comprehensive clinical evaluations and radiographic findings, in accordance with institutional guidelines. 2.2. Exclusion Criteria Patients with spinal deformities unrelated to Scheuermann’s disease such as idiopathic scoliosis or spondylolisthesis were excluded, as were those with neurological or neuromuscular disorders, those who underwent combined anterior-posterior surgical procedures, or those who required revision surgery due to complications such as instrumentation failure or pseudarthrosis. 2.3. Image Analysis Radiological images were analyzed using the RadiAnt DICOM Viewer (Version 2022.1.1, 64-bit; Build date: 17/08/2022), a commercially available software that enables precise quantification of angular and linear measurements. All measurements were independently performed by two experienced observers (consultant spine surgeons) to ensure consistency and reproducibility. In cases of significant inter-observer discrepancy, a third independent reviewer was consulted to resolve differences and reach a consensus. To evaluate the impact of Ponte osteotomies on kyphotic correction, several radiographic parameters were assessed. The primary outcome was the Cobb angle, defined as the angle formed by perpendicular lines to the superior endplate of the uppermost vertebra and the inferior endplate of the lowermost vertebra involved in the kyphotic deformity. This angle was measured preoperatively, immediately postoperatively and at follow up to determine the overall magnitude of correction achieved. Additionally, the local segmental correction at each osteotomized level was quantified by measuring the angle between the superior endplate of the vertebra above and the inferior endplate of the vertebra below the osteotomy site. The difference between preoperative and postoperative measurements at each level represented the localized corrective effect attributable to the Ponte osteotomy. Intervertebral disc space opening was also evaluated as an indicator of structural change following osteotomy. At each osteotomized level, the anterior, middle, and posterior disc heights were measured in centimeters. These measurements were obtained by drawing perpendicular lines from the upper vertebral endplate to the lower endplate at each region of the disc, allowing for a detailed analysis of changes in disc morphology associated with surgical intervention 3. Statistical Analysis Descriptive statistics were used to summarize and report the basic characteristics of the study cohort. A one-way ANOVA was conducted to compare outcomes across the three vertebral level groups. Where appropriate, post-hoc analyses were applied to further investigate group differences. The primary analysis initially focused on comparing improvements in Cobb angles following the intervention. Subsequently, the differential intervertebral disc opening at various vertebral levels was examined. For this analysis, a one-way ANOVA was again employed to determine whether certain vertebral levels exhibited greater disc space opening than others. The relationship between changes in disc height and the corresponding correction in Cobb angle was assessed. This relationship was evaluated using the Pearson correlation coefficient(r), which quantifies the degree of linear association between the two variables. A p-value < 0.05 was considered statistically significant. All statistical analyses were performed using SPSS (Version 26.0). 4. Results 4.1. Reporting of basic characteristics of data A total of 63 patients were enrolled in the study, including 27 males and 36 females (male: 42%, female: 58%). The age range was between 16 and 32 years, with a mean age of 20.4 years. The demographic and clinical characteristics of the patients who underwent the surgical intervention are summarized in Table 1 . Table 1 Demographic Data and clinical features of patients Parameter Value Number of patients 21 Age (years) Mean: 20.4 (Range: 16–32) Sex distribution Male: 42% (n = 9); Female: 58% (n = 12) Pelvic incidence (°) Mean: 38.2 (Range: 13.9–53.7) Sacral slope (°) Mean: 33.8 (Range: 19.3–48.1) Pelvic tilt (°) Mean: 6.5 (Range: 3.0–8.9) C7 sagittal vertical axis (SVA) (cm) Mean: 2.7 (Range: 0.3–5.95) Global tilt (°) Mean: 9.3 (Range: 0.3–24.2) GAP score Mean: 3.0 (Range: 0–5) Kyphosis apex level T7: 42%; T8: 58% EV distal vertebral level distribution T1: 28.6%; T2: 28.6%; T3: 28.6%; T5: 14.3% EV proximal vertebral level distribution T11: 14.3%; T12: 14.3%; L1: 42.9%; L2: 14.3%; L3: 14.3% T2–T5 kyphosis (°) Mean: 12.4 (Range: 4.2–26.6) T5–T10 kyphosis (°) Mean: 77.2 (Range: 71.0–88.4) T10–L2 kyphosis (°) Mean: 8.5 (Range: -23.4–41.2) Maximum kyphosis (°) Mean: 81.2 (Range: 77.0–89.2) L1–S1 lordosis (°) Mean: 68.3 (Range: 53.6–86.9) L4–S1 lordosis (°) Mean: 42.6 (Range: 30.0–53.3) Note : (°) stands for degree 4.2. Analysis of correction in Cobb Angle after surgery The effectiveness of Ponte osteotomies was evaluated through radiographic analysis of sagittal spinal alignment, specifically focusing on changes in Cobb angles across different vertebral levels. Preoperative and postoperative Cobb angles with sustained correction at follow up were measured to determine the degree of correction achieved at each segment, as shown in Table 2 and visually demonstrated in Fig. 1 . The average angular correction per vertebral level was also calculated, and notable improvements in kyphotic deformity were observed, particularly within the thoracolumbar region, which typically represents the apex of curvature in Scheuermann’s disease, as presented in Table 3 . An increase in lumbar lordosis was observed postoperatively, reflecting improved sagittal balance and alignment. When analyzing the levels where osteotomies were performed, the difference in kyphosis angle further supported the rationale for categorizing the osteotomies into three distinct groups. The first group, second group, and third group achieved an average angular correction of 1.85° (Fig. 2 ), 7.45° (Fig. 3), and 5.41° (Fig. 4), respectively. A more detailed evaluation revealed that the second and third groups demonstrated similar correction values, with no statistically significant difference between them (p > 0.05). In contrast, the first group showed a statistically significantly lower correction compared to the second and third groups. Specifically, the correction achieved at the T3–T4, T4–T5, and T5–T6 levels (first group) was notably less effective than that observed in the other two groups. Table 2 Preoperative and postoperative Cobb angles by vertebral level Vertebral Level Preoperative Cobb Angle (°) Postoperative Cobb Angle (°) Range P-value T1–T2 3.21 1.34 Pre: [0.6°–10.8°], Post: [0.3°–3.2°] 0.0092 * T2–T3 3.81 2.34 Pre: [1°–7.9°], Post: [0.5°–6°] 0.017 * T3–T4 5.8 6.3 Pre: [1.5°–10.4°], Post: [1.1°–14.1°] 0.334 T4–T5 10.32 9.18 Pre: [3.3°–21.4°], Post: [3°–15.3°] 0.237 T5–T6 18.57 13.66 Pre: [5.5°–34.8°], Post: [2.9°–27.2°] 0.0497 * T6–T7 24.17 20.0 Pre: [9.3°–42.3°], Post: [9°–34.5°] 0.083 T7–T8 25.9 18.14 Pre: [21.6°–31°], Post: [12.7°–22.5°] 0.0005 * T8–T9 23.82 13.44 Pre: [18°–27.7°], Post: [6.1°–20.1°] 0.0008 * T9–T10 17.6 12.86 Pre: [9.8°–24.3°], Post: [6.8°–21°] 0.004 * T10–T11 14.47 8.14 Pre: [-8.4°–31.9°], Post: [0.3°–17.1°] 0.03 * T11–T12 11.2 6.1 Pre: [-11.2°–29.7°], Post: [6.6°–19.6°] 0.05 T12–L1 5.38 -1.57 Pre: [-11.3°–13.3°], Post: [-7.4°–-5.5°] 0.0007 * L1–L2 -6.98 -7.17 Pre: [-15.2°–-2.4°], Post: [-13.4°–-1°] 0.45 L2–L3 -14.9 -5.1 Pre: [-25°–-11.1°], Post: [-10.3°–-1.6°] 0.005 * L3–L4 -17.1 -9.72 Pre: [-25.2°–-9.1°], Post: [-21.1°–-3.9°] 0.0002 * L4–L5 -28.6 -25.04 Pre: [-39.9°–-16.9°], Post: [-35°–-21.7°] 0.018 * L5–S1 -26.8 -23.2 Pre: [-40.3°–-13.6°], Post: [-33.3°–-10.1°] 0.09 Note : *P < .05 Table 3 Mean correction in Cobb angle by vertebral level Vertebral Level Mean Correction (°) Range T1–T2 1.87 0.2° – 9.6° T2–T3 1.47 0.2° – 3.6° T3–T4 -0.50 -9.7° – 3.1° T4–T5 1.14 -4.3° – 6.5° T5–T6 4.90 -2.2° – 17.1° T6–T7 4.17 -4.8° – 11.4° T7–T8 7.80 2.4° – 16.6° T8–T9 10.38 3.9° – 21.5° T9–T10 4.78 2.3° – 7.6° T10–T11 6.30 -8.7° – 15.2° T11–T12 5.10 -4.6° – 10.1° T12–L1 6.95 -7.6° – 16.0° L1–L2 0.18 -14.2° – 10.9° L2–L3 -9.80 -17.6° – -2.0° L3–L4 -7.38 -17.7° – 9.1° L4–L5 -3.58 -15.3° – -3.3° L5–S1 -3.60 -16.2° – 11.6° 4.3. Influence of intervertebral disc opening on kyphotic deformity correction: We also assessed the outcome of Ponte osteotomies in our study by observing changes in intervertebral disc height during surgical correction. It was noted that, as the vertebrae rotated posteriorly, anterior disc heights increased, central disc heights remained relatively stable, and posterior disc heights decreased, as illustrated in Figs. 5 and 6 . By comparing the preoperative disc heights with the postoperative measurements, we were able to determine the average anterior opening of each disc. These findings confirmed that the posterior disc height consistently decreased, the central disc height remained largely unchanged, and the anterior disc height showed a consistent increase across all vertebral levels, as presented in Table 4 . Table 4 Vertebral space opening at each level Vertebral Level Posterior Opening (mm) Central Opening (mm) Anterior Opening (mm) T3-T4 -0.21 -0.11 -0.14 T4-T5 0.0125 0.195 0.27775 T5-T6 0.01 0.13 0.206 T6-T7 -0.1 0.035 0.225 T7-T8 -0.2 0.007 0.2642 T8-T9 -0.23 0.041 0.1957 T9-T10 -0.085 0.074 0.257 T11-T12 0.023 0.066 0.196 T12-L1 0.055 0.071 0.14 L1-L2 -0.056 0.005 0.12 L2-L3 -0.12 -0.083 0.123 L3-L4 0.13 -0.03 -0.24 4.4. Correlation between anterior disc opening and Cobb angle correction The objective of this analysis was to evaluate the correlation between anterior disc opening and improvement in the kyphotic angle. Using the collected data, the correlation coefficient (R²) was calculated on a segmental basis between the Cobb angle correction (Δ) and the change in anterior disc height. The analysis revealed no statistically significant correlation between these two parameters. The average R² value at each level was low. Although marginally higher R² values were observed at the apex of the curve and the surrounding levels, these correlations also failed to reach statistical significance, as illustrated in Fig. 7 , 8 . 5. Discussion Kyphosis is defined as a curvature of the spine typically measuring between 20–40°. Scheuermann’s kyphosis affects approximately 8% of children in the United States and results in a structural or rigid kyphosis that can lead to various functional and cosmetic problems. Surgical treatment for this deformity is guided by the biomechanics of the patient, with the primary goal of restoring spinal and spinopelvic balance [2]. Although the combined anterior and posterior approach was historically considered the gold standard, recent advancements in technology and modern instrumentation have shifted trends toward less invasive techniques. In a retrospective meta-analysis of 1,147 patients comprising 605 patients treated with the posterior-only (PO) approach and 542 with the combined anterior-posterior approach, it was found that the posterior-only method yielded comparable results, while offering additional benefits such as reduced blood loss, shorter operation time, and fewer pulmonary complications [13,14,15]. In another study involving 80 patients, Ponte osteotomies combined with posterior spinal instrumented fusion were shown to be safe and effective in the treatment of Scheuermann’s kyphosis, with significantly reduced blood loss and operative time per osteotomy [16]. Furthermore, a meta-analysis of 659 studies involving 1,289 patients revealed that the posterior-only approach provided greater correction with a lower complication profile compared to the combined approach [17]. Our study reinforces existing evidence by demonstrating that Ponte osteotomies, when performed alongside posterior spinal fusion, are highly effective in the surgical correction of TK in patients with Scheuermann’s disease. Both statistically and clinically significant improvements were observed in sagittal alignment parameters and intervertebral disc morphology. In a case report of Scheuermann’s kyphosis treated, using a single posterior approach, approximately 40° of Cobb angle correction was achieved [5]. Another study involving 30 patients who underwent Ponte osteotomy and posterior spinal fusion with low-density implants reported a reduction in kyphosis to a mean value of 46.2° (range: 37–63°) [3]. Similarly, a separate study of 45 patients treated with a posterior-only approach reported a mean preoperative kyphosis angle of 79.8 ± 5.8° (range: 65–91°) and a mean postoperative angle of 44.6 ± 10.2° (range: 20–58°), indicating a significant reduction in the kyphotic curve [18]. In our study, the overall correction achieved in TK from 78.52° ± 6.47° to 44.67° ± 4.98° that aligns with previous findings, further supporting the effectiveness of Ponte osteotomies in facilitating a 30°–40° reduction, particularly in cases involving rigid deformities. This study also corroborates the biomechanical efficacy of Ponte osteotomies by demonstrating changes in both anterior and posterior disc heights, suggesting not only successful correction of the kyphotic curve but also partial restoration of disc space anatomy and segmental alignment. Importantly, the segmental analysis identified T9–T10 and T10–T11 as the levels demonstrating the greatest angular correction, suggesting that these thoracic segments may play a pivotal role in apex modulation of kyphotic deformities. This supports the hypothesis that osteotomies performed near the apex yield the most substantial angular improvements, as they directly address the regions of maximal structural rigidity and anterior vertebral wedging characteristic of Scheuermann’s disease. These findings align with the work of Cho et al. (2009) and others who advocate for targeted osteotomies at the apical levels to maximize correction while minimizing the extent of spinal fusion and associated operative morbidity [19,20]. The observed improvements in sagittal alignment including increased lumbar lordosis and normalization of the pelvic incidence, lumbar lordosis (PI–LL) mismatch, further highlight the comprehensive impact of thoracic correction on global spinal balance. Although pelvic parameters such as pelvic tilt and SVA were not available in this retrospective series, the noted improvement in lumbar lordosis indicates a favorable compensatory response and enhanced biomechanical efficiency following kyphotic curve correction. Notably, no major complications were observed, affirming the safety profile of Ponte osteotomies in carefully selected patients. The mean operative time and estimated blood loss were within acceptable clinical ranges, further supporting the feasibility and practicality of incorporating these osteotomies into routine surgical correction protocols for Scheuermann’s kyphosis. These outcomes are consistent with the findings of a recent meta-analysis conducted by Qingshan Li et al. (2021) [21]. 6. Conclusions This study underscores the efficacy of Ponte osteotomies in the surgical correction of TK associated with Scheuermann's disease, with particular emphasis on the influence of vertebral level on correction outcomes. Cobb angle analysis revealed that the most significant angular corrections were achieved at and below the T6–T7 levels, indicating that the mid-to-lower thoracic spine is more responsive to posterior osteotomies than the proximal thoracic region. These findings suggest that targeting these levels may enhance surgical outcomes and optimize sagittal plane realignment. Moreover, anterior disc opening was observed uniformly across all levels following osteotomy, irrespective of preoperative disc morphology. This demonstrates a predictable biomechanical response of the intervertebral discs to surgical correction, reinforcing the role of Ponte osteotomies in restoring anterior column height. Interestingly, no statistically significant correlation was found between the degree of Cobb angle correction and the increase in anterior disc height. This suggests that the correction of angular deformity may be influenced more by posterior structural release than by anterior disc expansion alone. Contrary to prevailing assumptions in the literature that emphasize the apex of kyphosis as the most effective site for correction, our findings indicate that osteotomies performed from T6–T7 downward yield more consistent and effective radiographic improvements. These insights have important implications for preoperative planning and may assist spine surgeons in selecting the most effective osteotomy levels to achieve maximal sagittal correction. 6.1. Limitations This study, while offering valuable insights into the segmental impact of Ponte osteotomies in the correction of Scheuermann’s kyphosis, is subject to several limitations. As a retrospective analysis, it is inherently limited by potential selection bias and lacks the methodological rigor of prospective, randomized studies. The relatively small sample size reduces statistical power and limits the generalizability of the findings to broader patient populations. The study focuses exclusively on radiographic parameters such as Cobb angle correction and anterior disc height changes without correlating these with clinical outcomes, including patient-reported pain relief, functional improvement, or quality of life metrics. This restricts the ability to evaluate the full clinical impact of the surgical intervention. The single-center design presents another limitation, as the results may reflect institution-specific surgical techniques and perioperative protocols that may not be universally applicable. Moreover, the lack of long-term follow-up data precludes assessment of the durability of surgical correction and the incidence of delayed complications, such as proximal or distal junctional kyphosis or recurrence of deformity. Finally, while this study effectively quantifies regional kyphosis correction and disc space remodeling, it does not incorporate global sagittal balance parameters, such as pelvic tilt, SVA, or T1-pelvic angle which are increasingly recognized as essential indicators of spinal realignment and long-term surgical success. Future research involving larger, multicenter cohorts, prospective study designs, and integration of both radiographic and clinical outcome measures will be crucial to validate and expand upon these finding Declarations Acknowledgment We are thankful to all the participants who sincerely helped us with this research. Funding information This study received no external funding. Conflict of interest statement All authors declare no conflicts of interest in this work. Ethical approval and informed consent Institutional ethical approval was achieved with ethical letter number (20180001473h ) and informed consent was waived . Data availability statement Data used in this study will be available on reasonable demand through a valid official email from the corresponding author. Declaration of generative AI and AI-assisted technologies in the writing The authors have used Grammarly tool during the writing of this article to improve the language and they have reviewed and edited the manuscript and they are fully responsible for the content of the published article. References Bezalel T., Carmeli E., Been E., Kalichman L. (2014). Scheuermann's disease: current diagnosis and treatment approach. Journal of Back and Musculoskeletal Rehabilitation , 27(4), 383–390. O’Donnell J.M., Wu W., Youn A., Mann A. and Swarup I., (2023). Scheuermann kyphosis: current concepts and management. Current Reviews in Musculoskeletal Medicine , 16(11), 521–530. Abousayed M., Elmiligui Y., Elhawary Y., ElNagar A., Elbromboly Y., (2024). The effectiveness of a low implant density in Scheurmann kyphosis in correcting the lumbar lordosis-pelvic incidence mismatch. The Egyptian Orthopaedic Journal , 59(3), 311–316. http://doi:10.4103/eoj.eoj_67_24. Chang-Hyun L., Young I.W., Young S.K. et al. (2021). Posterior-only versus combined anterior-posterior fusion in Scheuermann disease: a systematic review and meta-analysis. J. Neurosurg Spine , 34, 608–616. https://doi.org/10.3171/2020.7.SPINE201062. Joana P., Ana S.E., Pedro R., José M., Helder N., Jorge A. (2021). Adult scheuermann kyphosis surgical treatment by single posterior approach. Journal of Spine Research and Surgery , 3(3), 091–098. DOI:10.26502/fjsrs0033. Tomé-Bermejo F., Tsirikos A.I. (2012). Current concepts on Scheuermann kyphosis: Clinical presentation, diagnosis and controversies around treatment. Revista Española de Cirugía Ortopédica y Traumatología , 56, 491–505. http://doi:10.1016/j.recote.2012.10.002. Sardar Z.M., Ames R.J., Lenke L. (2019). Scheuermannʼs kyphosis: diagnosis, management, and selecting fusion levels. JAAOS-Journal of the American Academy of Orthopaedic Surgeons , 27(10), e462–e472. http://doi:10.5435/JAAOS-D-17-00748. Sebaaly A., Farjallah S., Kharrat K., Kreichati G., Daher M. (2022). Scheuermann's kyphosis: update on pathophysiology and surgical treatment. EFORT Open Reviews , 7(11), 782–791. https://doi.org/10.1530/EOR-22-0063 Nasto, L. A., Paolicelli, C., Sieczak, A., Ulisse, P., Cattolico, A., & Pola, E. (2025). Patient-Specific Rods vs Traditional Rods in Surgical Correction of Adult Spinal Deformities: A Case-Matched Study. Annali Italiani di Chirurgia , 96 (1), 116-123. Hollyer I., Johnson T.R., Kha S.T. et al. (2023). Introduction of a novel sequential approach to the ponte osteotomy to minimize spinal canal exposure. Children , 10(3), 470. http://doi.org/10.3390/children10030470. Temponi E.F., de Macedo R.D., Pedrosa L.O., Fontes B.P. (2015). Scheuermann's kyphosis: comparison between the posterior approach associated with Smith-Petersen osteotomy and combined anterior-posterior fusion. Revista Brasileira De Ortopedia , 46, 709–717. https://doi.org/10.1016/S2255-4971(15)30329-3. Chady O., Lynn P., René M.C., Ralph J.B.S., Carmen L.A.V.L. (2025). Early evaluation and treatment of thoracolumbar kyphosis in children with achondroplasia. European Spine Journal, 34, 1221–1228. https://doi.org/10.1007/s00586-025-08692-5. Chen Z., Rong L. (2016). Comparison of combined anterior-posterior approach versus posterior-only approach in treating adolescent idiopathic scoliosis: a meta-analysis. European Spine Journal , 25(2), 363–371. Zhang H.Q., Wang Y.X., Guo C.F. et al. (2011). Posterior-only surgery with strong halo-femoral traction for the treatment of adolescent idiopathic scoliotic curves more than 100°. International Orthopaedics , 35(7), 1037–1042. Shen F., Zhou B., Li Q. et al. (2015). Posterior-only spinal release combined with derotation, translation, segmental correction, and an in-situ rod-contouring technique for treatment of severe and rigid scoliosis. Journal of Neurosurgery: Spine , 22(2), 194–198. Nasto L.A., Mousavi Nasab S.H., Sieczak A., Cattolico A., Ulisse P., Pola E. (2024). Ponte osteotomies for treatment of spinal deformities: they are not all made equal. European Spine Journal , 33(7), 2787–2793. http://doi.org/10.1007/s00586-024-08334-2. Huq S., Ehresman J., Cottrill E., Ahmed A.K., Pennington Z., Westbroek E.M., Sciubba D.M. (2020). Treatment approaches for Scheuermann kyphosis: a systematic review of historic and current management. Journal of Neurosurgery: Spine , 32(2), 235–247. https://doi.org/10.3171/2019.8.SPINE19500. Adem C., Akif A., Yalkin C., Hakan S., Temel T., Mehmet A.K. (2017). Posterior-only approach with pedicle screws for the correction of Scheuermann's kyphosis. Asian Spine Journal , 11(4), 513–519. https://doi.org/10.4184/asj.2017.11.4.513. Cho K.J., Lenke L.G., Bridwell K.H., Kamiya M., Sides B. (2009). Selection of the optimal distal fusion level in posterior instrumentation and fusion for thoracic hyperkyphosis: the sagittal stable vertebra concept. Spine , 34(8), 765–770. Kira F.S., Kenneth R.K., Kenneth D.I., Lindsay M.A., David L.S. (2021). Master’s Surgical Technique: Operative Treatment of Scheuermann’s Kyphosis. Journal of the Pediatric Orthopaedic Society of North America , 3(1), 222. https://doi.org/10.55275/JPOSNA-2021-222. Qingshan Li. (2021). Surgical Procedures Used for Correction of Scheuermann’s Kyphosis: A Meta-Analysis. Pain Research and Management , 2021(1), 2142964. https://doi.org/10.1155/2021/2142964 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6686863","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":464259494,"identity":"080d5b05-ac87-475d-b1c8-511d43a0f89a","order_by":0,"name":"Luigi Aurelio Nasto","email":"","orcid":"","institution":"Azienda Ospedaliera Universitaria Università degli Studi della Campania Luigi Vanvitelli","correspondingAuthor":false,"prefix":"","firstName":"Luigi","middleName":"Aurelio","lastName":"Nasto","suffix":""},{"id":464259497,"identity":"7069c4d8-2dd0-4b3c-bb7a-04076eef495f","order_by":1,"name":"Alessandro 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Vanvitelli","correspondingAuthor":false,"prefix":"","firstName":"Paolo","middleName":"","lastName":"Ulisse","suffix":""},{"id":464259502,"identity":"98f3f283-7e8f-4d40-80b4-451019db327d","order_by":5,"name":"Enrico Pola","email":"","orcid":"","institution":"Azienda Ospedaliera Universitaria Università degli Studi della Campania Luigi Vanvitelli","correspondingAuthor":false,"prefix":"","firstName":"Enrico","middleName":"","lastName":"Pola","suffix":""}],"badges":[],"createdAt":"2025-05-17 12:08:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6686863/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6686863/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83814790,"identity":"7dc89c35-85fa-4977-bb59-a22415650b71","added_by":"auto","created_at":"2025-06-03 07:31:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":55818,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMean Cobb angles comparison between preoperative and postoperative values\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6686863/v1/e750063dec948c71efc18e9f.png"},{"id":83814788,"identity":"473359dc-c3fc-46f7-a482-71189d29ea15","added_by":"auto","created_at":"2025-06-03 07:31:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":10444,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFirst group angle correction\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6686863/v1/59382b0ab20289071e210078.png"},{"id":83814787,"identity":"d26dc012-217f-454b-b36c-c22f3269c31f","added_by":"auto","created_at":"2025-06-03 07:31:42","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":8648,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSecond group angle correction\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6686863/v1/59d3afd58aca6aa1e98a94be.png"},{"id":83814791,"identity":"7d303f22-68b0-4b53-ad51-44a9ca7de590","added_by":"auto","created_at":"2025-06-03 07:31:42","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":13070,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThird group angle correction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003e(Pre and post-operative Cobb angle correction in three groups\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eNote:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e \u003c/em\u003e(\u003cem\u003eBlue line: preoperative, Green line: post-operative\u003c/em\u003e)\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6686863/v1/fbb55235260d19b02fe69c7a.png"},{"id":83814796,"identity":"38ada28a-825e-4fc5-93dc-edd8a54f6eb2","added_by":"auto","created_at":"2025-06-03 07:31:42","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":184982,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIntervertebral disc height changes with Ponte Osteotomies showing increased anterior height, stable central height and decreased posterior height\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6686863/v1/fac3665e6b018e001c169f2c.png"},{"id":83815803,"identity":"d7f88e0d-2d74-4b24-977a-2de566f41d9c","added_by":"auto","created_at":"2025-06-03 07:39:42","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":240988,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIntervertebral disc height changes with Ponte Osteotomies showing increased anterior height, stable central height and decreased posterior height\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-6686863/v1/044caae3869ef36295a9e5a9.png"},{"id":83814795,"identity":"23598449-25ab-4b2c-b7b0-31191b316469","added_by":"auto","created_at":"2025-06-03 07:31:42","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":135056,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIncrease in anterior, central, and posterior disc heights following Ponte Osteotomies\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-6686863/v1/68fbf555998f2c83d58ae544.png"},{"id":83815802,"identity":"0bc2bb74-2088-4536-8211-5228dedf955e","added_by":"auto","created_at":"2025-06-03 07:39:42","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":143668,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIncrease in anterior, central, and posterior disc heights following Ponte osteotomies, with more significant opening at the T5–T6 level (determination of Coefficient, R²)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-6686863/v1/993eaa361ca4264880bfd95c.png"},{"id":88477801,"identity":"4d01ada0-2cac-46b5-967c-d5ef34cecf11","added_by":"auto","created_at":"2025-08-06 22:31:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2042584,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6686863/v1/5bb0ee0c-db21-49d7-8c33-72c28e57814b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy of Ponte Osteotomies in the Surgical Treatment of Scheuermann's Disease: An Analysis of Optimal Spinal Levels for Correction","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eScheuermann's disease, also known as \u003cem\u003eJuvenile Vertebral Osteochondrosis\u003c/em\u003e, is the main cause of adolescent hyperkyphosis in the thoracic and thoracolumbar spine [1]. Horgel Welfer Scheuermann defined this disease for the first time in 1920 [2]. It targets the vertebral endplate's growth cartilage, leading to vertebral body wedging, Schmorl's nodes, and disc degeneration. It can cause chronic back pain, neurologic impairment, and cosmetic problems in patients. It is considered one of the most common sagittal angular spinal deformities, with an incidence of 4\u0026ndash;8% and no gender discrimination [3]. Although there is no known cause of this deformity, different theories include genetic mutation involving a mutant major gene and candidate genes, altered biomechanics, idiopathic juvenile osteoporosis, and elevated growth hormone levels, with well-documented physiological impacts and physical effects [2,4]. The disease is classified into two types, with the typical form being more prevalent than the atypical one, and it primarily affects the thoracic spine, potentially leading to thoracic hyperkyphosis with lumbar lordosis [5]. Differential diagnosis includes postural kyphosis, sequelae of vertebral compression fracture, curved back, spondyloepiphyseal dysplasia, osteochondral dystrophy, and spondylodiscitis, all of which must be ruled out before proceeding with treatment [6].\u003c/p\u003e \u003cp\u003eDifferent treatment options include non-surgical and surgical management. Indications for conservative management are thoracic kyphosis (TK)\u0026thinsp;\u0026gt;\u0026thinsp;50\u0026deg;, or kyphosis\u0026thinsp;\u0026gt;\u0026thinsp;45\u0026deg; with radiographic stigmata such as Schmorl\u0026rsquo;s nodes or wedged vertebrae. These include physiotherapy, exercises, anti-inflammatory medications, and orthopedic corsets, and are considered primary management strategies, emphasizing early intervention for best outcomes [7]. Surgery is reserved for adult patients with severe deformity (i.e., kyphosis over 75\u0026deg;), functional disability with severe pain, neurological impairments, cosmetic concerns, cardiothoracic problems (Cobb\u0026thinsp;\u0026gt;\u0026thinsp;100\u0026deg;), or those not responding to conservative meaures [5,8]. Different surgical approaches include anterior release, posterior approach (even with Patient specific pre-contoured rods (PSRs) and instrumentation[9]), and the combination approach\u0026mdash;each with its benefits and drawbacks. The gold standard for correcting this disease was considered apical anterior release and fusion followed by posterior spinal fusion, which was established in 1975 [4]. With the introduction of multi-segmental compression instruments, the trend shifted toward the posterior approach with the introduction of Ponte osteotomy and sagittal subtraction osteotomy. Ponte described the Ponte osteotomy for sagittal kyphosis in 1987 [10]. With advancements in this technique, modern instrumentation, and the use of pedicle screws, it is now widely used for deformities in the coronal, sagittal, and rotational planes, enabling effective correction using a singular posterior approach. Advantages of this technique include a single-staged procedure, no compromise to the anterior blood supply of the spinal cord, increased level of safety, no complications from thoracoscopy or thoracotomy, and minimized exposure of the spinal canal. This method also reduces surgical duration and blood loss compared to the combined approach, which is more invasive and generally reserved for severe deformities [11].\u003c/p\u003e \u003cp\u003eThe aim of our study is to evaluate the effectiveness of Ponte osteotomies in treating Scheuermann's disease. We aim to identify specific vertebral levels where osteotomies offer better correction. Additionally, we explore the osteotomies' impact on intervertebral disc opening and whether a relationship exists between the extent of correction and disc space expansion. Insights from this research can guide surgeons in preoperative planning, determining the number of osteotomies, and possibly reducing surgery time and hemorrhagic risk.\u003c/p\u003e"},{"header":"2. Methodology","content":"\u003cp\u003eThis retrospective observational study was conducted at the Orthopedics Department of A.O.U. Luigi Vanvitelli over a four-year period, from 2018 to 2022, to evaluate the efficacy of high-density instrumented posterior spinal fusion combined with Ponte osteotomies in patients with Scheuermann\u0026rsquo;s kyphosis. Our local ethical committee (Comitato Etico Aziendale) approved the study (Ethical Approval No. 20180001473h), and written informed consent was waived because of retrospective study. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [12].\u003c/p\u003e \u003cp\u003ePatients with a confirmed clinical and radiological diagnosis of Scheuermann\u0026rsquo;s disease who underwent only posterior surgical correction were included. Segmental correction was assessed by comparing preoperative and postoperative Cobb angles at each vertebral level where a Ponte osteotomy was performed. Additionally, changes in intervertebral disc morphology were evaluated by measuring anterior, middle, and posterior disc heights before surgery, after surgery, and at follow up. For regional analysis, vertebral levels were categorized into three groups: the upper thoracic group (T3\u0026ndash;T4, T4\u0026ndash;T5, T5\u0026ndash;T6), the middle thoracic group (T6\u0026ndash;T7, T7\u0026ndash;T8, T8\u0026ndash;T9), and the lower thoracic group (T9\u0026ndash;T10, T10\u0026ndash;T11, T11\u0026ndash;T12). This stratification allowed for a detailed comparison of the corrective impact across different thoracic regions.\u003c/p\u003e \u003cp\u003eRadiographic assessments were performed using standardized anteroposterior and lateral weight-bearing radiographs obtained preoperatively, immediately postoperatively, and at follow-up. All imaging was conducted using consistent protocols by a dedicated radiology team within the same institution, ensuring measurement accuracy and reproducibility.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Participants\u003c/h2\u003e \u003cp\u003eThe study cohort included 63 patients (42% male and 58% female), aged between 14 and 25 years, with a mean age of 20.42 years. All patients underwent posterior spinal fusion with Ponte osteotomies using high-density instrumentation, performed by a single surgeon with expertise in spinal surgery. Surgical indications were determined based on comprehensive clinical evaluations and radiographic findings, in accordance with institutional guidelines.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Exclusion Criteria\u003c/h2\u003e \u003cp\u003ePatients with spinal deformities unrelated to Scheuermann\u0026rsquo;s disease such as idiopathic scoliosis or spondylolisthesis were excluded, as were those with neurological or neuromuscular disorders, those who underwent combined anterior-posterior surgical procedures, or those who required revision surgery due to complications such as instrumentation failure or pseudarthrosis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Image Analysis\u003c/h2\u003e \u003cp\u003eRadiological images were analyzed using the RadiAnt DICOM Viewer (Version 2022.1.1, 64-bit; Build date: 17/08/2022), a commercially available software that enables precise quantification of angular and linear measurements. All measurements were independently performed by two experienced observers (consultant spine surgeons) to ensure consistency and reproducibility. In cases of significant inter-observer discrepancy, a third independent reviewer was consulted to resolve differences and reach a consensus.\u003c/p\u003e \u003cp\u003eTo evaluate the impact of Ponte osteotomies on kyphotic correction, several radiographic parameters were assessed. The primary outcome was the Cobb angle, defined as the angle formed by perpendicular lines to the superior endplate of the uppermost vertebra and the inferior endplate of the lowermost vertebra involved in the kyphotic deformity. This angle was measured preoperatively, immediately postoperatively and at follow up to determine the overall magnitude of correction achieved.\u003c/p\u003e \u003cp\u003eAdditionally, the local segmental correction at each osteotomized level was quantified by measuring the angle between the superior endplate of the vertebra above and the inferior endplate of the vertebra below the osteotomy site. The difference between preoperative and postoperative measurements at each level represented the localized corrective effect attributable to the Ponte osteotomy.\u003c/p\u003e \u003cp\u003eIntervertebral disc space opening was also evaluated as an indicator of structural change following osteotomy. At each osteotomized level, the anterior, middle, and posterior disc heights were measured in centimeters. These measurements were obtained by drawing perpendicular lines from the upper vertebral endplate to the lower endplate at each region of the disc, allowing for a detailed analysis of changes in disc morphology associated with surgical intervention\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Statistical Analysis","content":"\u003cp\u003eDescriptive statistics were used to summarize and report the basic characteristics of the study cohort. A one-way ANOVA was conducted to compare outcomes across the three vertebral level groups. Where appropriate, post-hoc analyses were applied to further investigate group differences. The primary analysis initially focused on comparing improvements in Cobb angles following the intervention. Subsequently, the differential intervertebral disc opening at various vertebral levels was examined. For this analysis, a one-way ANOVA was again employed to determine whether certain vertebral levels exhibited greater disc space opening than others.\u003c/p\u003e \u003cp\u003eThe relationship between changes in disc height and the corresponding correction in Cobb angle was assessed. This relationship was evaluated using the Pearson correlation coefficient(r), which quantifies the degree of linear association between the two variables. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. All statistical analyses were performed using SPSS (Version 26.0).\u003c/p\u003e"},{"header":"4. Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003e4.1. Reporting of basic characteristics of data\u003c/h2\u003e\n \u003cp\u003eA total of 63 patients were enrolled in the study, including 27 males and 36 females (male: 42%, female: 58%). The age range was between 16 and 32 years, with a mean age of 20.4 years. The demographic and clinical characteristics of the patients who underwent the surgical intervention are summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic Data and clinical features of patients\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eParameter\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eValue\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean: 20.4 (Range: 16\u0026ndash;32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex distribution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale: 42% (n\u0026thinsp;=\u0026thinsp;9); Female: 58% (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePelvic incidence (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean: 38.2 (Range: 13.9\u0026ndash;53.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSacral slope (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean: 33.8 (Range: 19.3\u0026ndash;48.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePelvic tilt (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean: 6.5 (Range: 3.0\u0026ndash;8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC7 sagittal vertical axis (SVA) (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean: 2.7 (Range: 0.3\u0026ndash;5.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGlobal tilt (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean: 9.3 (Range: 0.3\u0026ndash;24.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGAP score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean: 3.0 (Range: 0\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKyphosis apex level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT7: 42%; T8: 58%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEV distal vertebral level distribution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT1: 28.6%; T2: 28.6%; T3: 28.6%; T5: 14.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEV proximal vertebral level distribution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT11: 14.3%; T12: 14.3%; L1: 42.9%; L2: 14.3%; L3: 14.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT2\u0026ndash;T5 kyphosis (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean: 12.4 (Range: 4.2\u0026ndash;26.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT5\u0026ndash;T10 kyphosis (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean: 77.2 (Range: 71.0\u0026ndash;88.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT10\u0026ndash;L2 kyphosis (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean: 8.5 (Range: -23.4\u0026ndash;41.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMaximum kyphosis (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean: 81.2 (Range: 77.0\u0026ndash;89.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL1\u0026ndash;S1 lordosis (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean: 68.3 (Range: 53.6\u0026ndash;86.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL4\u0026ndash;S1 lordosis (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean: 42.6 (Range: 30.0\u0026ndash;53.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\u003cstrong\u003eNote\u003c/strong\u003e: \u003cem\u003e(\u0026deg;) stands for degree\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003e4.2. Analysis of correction in Cobb Angle after surgery\u003c/h2\u003e\n \u003cp\u003eThe effectiveness of Ponte osteotomies was evaluated through radiographic analysis of sagittal spinal alignment, specifically focusing on changes in Cobb angles across different vertebral levels. Preoperative and postoperative Cobb angles with sustained correction at follow up were measured to determine the degree of correction achieved at each segment, as shown in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e and visually demonstrated in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The average angular correction per vertebral level was also calculated, and notable improvements in kyphotic deformity were observed, particularly within the thoracolumbar region, which typically represents the apex of curvature in Scheuermann\u0026rsquo;s disease, as presented in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. An increase in lumbar lordosis was observed postoperatively, reflecting improved sagittal balance and alignment. When analyzing the levels where osteotomies were performed, the difference in kyphosis angle further supported the rationale for categorizing the osteotomies into three distinct groups. The first group, second group, and third group achieved an average angular correction of 1.85\u0026deg; (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e), 7.45\u0026deg; (Fig. 3), and 5.41\u0026deg; (Fig. 4), respectively. A more detailed evaluation revealed that the second and third groups demonstrated similar correction values, with no statistically significant difference between them (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In contrast, the first group showed a statistically significantly lower correction compared to the second and third groups. Specifically, the correction achieved at the T3\u0026ndash;T4, T4\u0026ndash;T5, and T5\u0026ndash;T6 levels (first group) was notably less effective than that observed in the other two groups.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePreoperative and postoperative Cobb angles by vertebral level\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eVertebral Level\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePreoperative Cobb Angle (\u0026deg;)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePostoperative Cobb Angle (\u0026deg;)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eRange\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT1\u0026ndash;T2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre: [0.6\u0026deg;\u0026ndash;10.8\u0026deg;], Post: [0.3\u0026deg;\u0026ndash;3.2\u0026deg;]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0092\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT2\u0026ndash;T3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre: [1\u0026deg;\u0026ndash;7.9\u0026deg;], Post: [0.5\u0026deg;\u0026ndash;6\u0026deg;]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.017\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT3\u0026ndash;T4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre: [1.5\u0026deg;\u0026ndash;10.4\u0026deg;], Post: [1.1\u0026deg;\u0026ndash;14.1\u0026deg;]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.334\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT4\u0026ndash;T5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre: [3.3\u0026deg;\u0026ndash;21.4\u0026deg;], Post: [3\u0026deg;\u0026ndash;15.3\u0026deg;]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.237\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT5\u0026ndash;T6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre: [5.5\u0026deg;\u0026ndash;34.8\u0026deg;], Post: [2.9\u0026deg;\u0026ndash;27.2\u0026deg;]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0497\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT6\u0026ndash;T7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre: [9.3\u0026deg;\u0026ndash;42.3\u0026deg;], Post: [9\u0026deg;\u0026ndash;34.5\u0026deg;]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT7\u0026ndash;T8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre: [21.6\u0026deg;\u0026ndash;31\u0026deg;], Post: [12.7\u0026deg;\u0026ndash;22.5\u0026deg;]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0005\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT8\u0026ndash;T9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre: [18\u0026deg;\u0026ndash;27.7\u0026deg;], Post: [6.1\u0026deg;\u0026ndash;20.1\u0026deg;]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0008\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT9\u0026ndash;T10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre: [9.8\u0026deg;\u0026ndash;24.3\u0026deg;], Post: [6.8\u0026deg;\u0026ndash;21\u0026deg;]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.004\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT10\u0026ndash;T11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre: [-8.4\u0026deg;\u0026ndash;31.9\u0026deg;], Post: [0.3\u0026deg;\u0026ndash;17.1\u0026deg;]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.03\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT11\u0026ndash;T12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre: [-11.2\u0026deg;\u0026ndash;29.7\u0026deg;], Post: [6.6\u0026deg;\u0026ndash;19.6\u0026deg;]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT12\u0026ndash;L1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre: [-11.3\u0026deg;\u0026ndash;13.3\u0026deg;], Post: [-7.4\u0026deg;\u0026ndash;-5.5\u0026deg;]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0007\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL1\u0026ndash;L2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-6.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-7.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre: [-15.2\u0026deg;\u0026ndash;-2.4\u0026deg;], Post: [-13.4\u0026deg;\u0026ndash;-1\u0026deg;]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL2\u0026ndash;L3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-14.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre: [-25\u0026deg;\u0026ndash;-11.1\u0026deg;], Post: [-10.3\u0026deg;\u0026ndash;-1.6\u0026deg;]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.005\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL3\u0026ndash;L4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-17.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-9.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre: [-25.2\u0026deg;\u0026ndash;-9.1\u0026deg;], Post: [-21.1\u0026deg;\u0026ndash;-3.9\u0026deg;]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0002\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL4\u0026ndash;L5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-28.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-25.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre: [-39.9\u0026deg;\u0026ndash;-16.9\u0026deg;], Post: [-35\u0026deg;\u0026ndash;-21.7\u0026deg;]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.018\u003csup\u003e\u003cem\u003e*\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL5\u0026ndash;S1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-26.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-23.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre: [-40.3\u0026deg;\u0026ndash;-13.6\u0026deg;], Post: [-33.3\u0026deg;\u0026ndash;-10.1\u0026deg;]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003cstrong\u003eNote\u003c/strong\u003e: \u003cem\u003e*P\u0026thinsp;\u0026lt;\u0026thinsp;.05\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"char\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMean correction in Cobb angle by vertebral level\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eVertebral Level\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMean Correction (\u0026deg;)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eRange\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT1\u0026ndash;T2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.2\u0026deg; \u0026ndash; 9.6\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT2\u0026ndash;T3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.2\u0026deg; \u0026ndash; 3.6\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT3\u0026ndash;T4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-9.7\u0026deg; \u0026ndash; 3.1\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT4\u0026ndash;T5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-4.3\u0026deg; \u0026ndash; 6.5\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT5\u0026ndash;T6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-2.2\u0026deg; \u0026ndash; 17.1\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT6\u0026ndash;T7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-4.8\u0026deg; \u0026ndash; 11.4\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT7\u0026ndash;T8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.4\u0026deg; \u0026ndash; 16.6\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT8\u0026ndash;T9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.9\u0026deg; \u0026ndash; 21.5\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT9\u0026ndash;T10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.3\u0026deg; \u0026ndash; 7.6\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT10\u0026ndash;T11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-8.7\u0026deg; \u0026ndash; 15.2\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT11\u0026ndash;T12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-4.6\u0026deg; \u0026ndash; 10.1\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT12\u0026ndash;L1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-7.6\u0026deg; \u0026ndash; 16.0\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL1\u0026ndash;L2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-14.2\u0026deg; \u0026ndash; 10.9\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL2\u0026ndash;L3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-9.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-17.6\u0026deg; \u0026ndash; -2.0\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL3\u0026ndash;L4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-7.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-17.7\u0026deg; \u0026ndash; 9.1\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL4\u0026ndash;L5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-3.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-15.3\u0026deg; \u0026ndash; -3.3\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL5\u0026ndash;S1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-3.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-16.2\u0026deg; \u0026ndash; 11.6\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003e4.3. Influence of intervertebral disc opening on kyphotic deformity correction:\u003c/h2\u003e\n \u003cp\u003eWe also assessed the outcome of Ponte osteotomies in our study by observing changes in intervertebral disc height during surgical correction. It was noted that, as the vertebrae rotated posteriorly, anterior disc heights increased, central disc heights remained relatively stable, and posterior disc heights decreased, as illustrated in Figs. \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003eBy comparing the preoperative disc heights with the postoperative measurements, we were able to determine the average \u003cem\u003eanterior opening\u003c/em\u003e of each disc. These findings confirmed that the posterior disc height consistently decreased, the central disc height remained largely unchanged, and the anterior disc height showed a consistent increase across all vertebral levels, as presented in Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eVertebral space opening at each level\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eVertebral Level\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePosterior Opening (mm)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eCentral Opening (mm)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eAnterior Opening (mm)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT3-T4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT4-T5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.195\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.27775\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT5-T6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.206\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT6-T7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.225\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT7-T8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.2642\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT8-T9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1957\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT9-T10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.085\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.074\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.257\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT11-T12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.196\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT12-L1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.071\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL1-L2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL2-L3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.123\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL3-L4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003e4.4. Correlation between anterior disc opening and Cobb angle correction\u003c/h2\u003e\n \u003cp\u003eThe objective of this analysis was to evaluate the correlation between anterior disc opening and improvement in the kyphotic angle. Using the collected data, the correlation coefficient (R\u0026sup2;) was calculated on a segmental basis between the Cobb angle correction (\u0026Delta;) and the change in anterior disc height. The analysis revealed no statistically significant correlation between these two parameters. The average R\u0026sup2; value at each level was low. Although marginally higher R\u0026sup2; values were observed at the apex of the curve and the surrounding levels, these correlations also failed to reach statistical significance, as illustrated in Fig. \u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003e,\u003cspan class=\"InternalRef\"\u003e8\u003c/span\u003e.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"5. Discussion","content":"\u003cp\u003eKyphosis is defined as a curvature of the spine typically measuring between 20\u0026ndash;40\u0026deg;. Scheuermann\u0026rsquo;s kyphosis affects approximately 8% of children in the United States and results in a structural or rigid kyphosis that can lead to various functional and cosmetic problems. Surgical treatment for this deformity is guided by the biomechanics of the patient, with the primary goal of restoring spinal and spinopelvic balance [2]. Although the combined anterior and posterior approach was historically considered the gold standard, recent advancements in technology and modern instrumentation have shifted trends toward less invasive techniques. In a retrospective meta-analysis of 1,147 patients comprising 605 patients treated with the posterior-only (PO) approach and 542 with the combined anterior-posterior approach, it was found that the posterior-only method yielded comparable results, while offering additional benefits such as reduced blood loss, shorter operation time, and fewer pulmonary complications [13,14,15]. In another study involving 80 patients, Ponte osteotomies combined with posterior spinal instrumented fusion were shown to be safe and effective in the treatment of Scheuermann\u0026rsquo;s kyphosis, with significantly reduced blood loss and operative time per osteotomy [16]. Furthermore, a meta-analysis of 659 studies involving 1,289 patients revealed that the posterior-only approach provided greater correction with a lower complication profile compared to the combined approach [17]. Our study reinforces existing evidence by demonstrating that Ponte osteotomies, when performed alongside posterior spinal fusion, are highly effective in the surgical correction of TK in patients with Scheuermann\u0026rsquo;s disease.\u003c/p\u003e \u003cp\u003eBoth statistically and clinically significant improvements were observed in sagittal alignment parameters and intervertebral disc morphology. In a case report of Scheuermann\u0026rsquo;s kyphosis treated, using a single posterior approach, approximately 40\u0026deg; of Cobb angle correction was achieved [5]. Another study involving 30 patients who underwent Ponte osteotomy and posterior spinal fusion with low-density implants reported a reduction in kyphosis to a mean value of 46.2\u0026deg; (range: 37\u0026ndash;63\u0026deg;) [3]. Similarly, a separate study of 45 patients treated with a posterior-only approach reported a mean preoperative kyphosis angle of 79.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8\u0026deg; (range: 65\u0026ndash;91\u0026deg;) and a mean postoperative angle of 44.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2\u0026deg; (range: 20\u0026ndash;58\u0026deg;), indicating a significant reduction in the kyphotic curve [18].\u003c/p\u003e \u003cp\u003eIn our study, the overall correction achieved in TK from 78.52\u0026deg; \u0026plusmn; 6.47\u0026deg; to 44.67\u0026deg; \u0026plusmn; 4.98\u0026deg; that aligns with previous findings, further supporting the effectiveness of Ponte osteotomies in facilitating a 30\u0026deg;\u0026ndash;40\u0026deg; reduction, particularly in cases involving rigid deformities. This study also corroborates the biomechanical efficacy of Ponte osteotomies by demonstrating changes in both anterior and posterior disc heights, suggesting not only successful correction of the kyphotic curve but also partial restoration of disc space anatomy and segmental alignment.\u003c/p\u003e \u003cp\u003eImportantly, the segmental analysis identified T9\u0026ndash;T10 and T10\u0026ndash;T11 as the levels demonstrating the greatest angular correction, suggesting that these thoracic segments may play a pivotal role in apex modulation of kyphotic deformities. This supports the hypothesis that osteotomies performed near the apex yield the most substantial angular improvements, as they directly address the regions of maximal structural rigidity and anterior vertebral wedging characteristic of Scheuermann\u0026rsquo;s disease. These findings align with the work of Cho \u003cem\u003eet al.\u003c/em\u003e (2009) and others who advocate for targeted osteotomies at the apical levels to maximize correction while minimizing the extent of spinal fusion and associated operative morbidity [19,20].\u003c/p\u003e \u003cp\u003eThe observed improvements in sagittal alignment including increased lumbar lordosis and normalization of the pelvic incidence, lumbar lordosis (PI\u0026ndash;LL) mismatch, further highlight the comprehensive impact of thoracic correction on global spinal balance. Although pelvic parameters such as pelvic tilt and SVA were not available in this retrospective series, the noted improvement in lumbar lordosis indicates a favorable compensatory response and enhanced biomechanical efficiency following kyphotic curve correction. Notably, no major complications were observed, affirming the safety profile of Ponte osteotomies in carefully selected patients. The mean operative time and estimated blood loss were within acceptable clinical ranges, further supporting the feasibility and practicality of incorporating these osteotomies into routine surgical correction protocols for Scheuermann\u0026rsquo;s kyphosis. These outcomes are consistent with the findings of a recent meta-analysis conducted by Qingshan Li et al. (2021) [21].\u003c/p\u003e"},{"header":"6. Conclusions","content":"\u003cp\u003eThis study underscores the efficacy of Ponte osteotomies in the surgical correction of TK associated with Scheuermann's disease, with particular emphasis on the influence of vertebral level on correction outcomes. Cobb angle analysis revealed that the most significant angular corrections were achieved at and below the T6\u0026ndash;T7 levels, indicating that the mid-to-lower thoracic spine is more responsive to posterior osteotomies than the proximal thoracic region. These findings suggest that targeting these levels may enhance surgical outcomes and optimize sagittal plane realignment.\u003c/p\u003e \u003cp\u003eMoreover, anterior disc opening was observed uniformly across all levels following osteotomy, irrespective of preoperative disc morphology. This demonstrates a predictable biomechanical response of the intervertebral discs to surgical correction, reinforcing the role of Ponte osteotomies in restoring anterior column height.\u003c/p\u003e \u003cp\u003eInterestingly, no statistically significant correlation was found between the degree of Cobb angle correction and the increase in anterior disc height. This suggests that the correction of angular deformity may be influenced more by posterior structural release than by anterior disc expansion alone. Contrary to prevailing assumptions in the literature that emphasize the apex of kyphosis as the most effective site for correction, our findings indicate that osteotomies performed from T6\u0026ndash;T7 downward yield more consistent and effective radiographic improvements. These insights have important implications for preoperative planning and may assist spine surgeons in selecting the most effective osteotomy levels to achieve maximal sagittal correction.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e6.1. Limitations\u003c/h2\u003e \u003cp\u003eThis study, while offering valuable insights into the segmental impact of Ponte osteotomies in the correction of Scheuermann\u0026rsquo;s kyphosis, is subject to several limitations. As a retrospective analysis, it is inherently limited by potential selection bias and lacks the methodological rigor of prospective, randomized studies. The relatively small sample size reduces statistical power and limits the generalizability of the findings to broader patient populations. The study focuses exclusively on radiographic parameters such as Cobb angle correction and anterior disc height changes without correlating these with clinical outcomes, including patient-reported pain relief, functional improvement, or quality of life metrics. This restricts the ability to evaluate the full clinical impact of the surgical intervention.\u003c/p\u003e \u003cp\u003eThe single-center design presents another limitation, as the results may reflect institution-specific surgical techniques and perioperative protocols that may not be universally applicable. Moreover, the lack of long-term follow-up data precludes assessment of the durability of surgical correction and the incidence of delayed complications, such as proximal or distal junctional kyphosis or recurrence of deformity.\u003c/p\u003e \u003cp\u003eFinally, while this study effectively quantifies regional kyphosis correction and disc space remodeling, it does not incorporate global sagittal balance parameters, such as pelvic tilt, SVA, or T1-pelvic angle which are increasingly recognized as essential indicators of spinal realignment and long-term surgical success. Future research involving larger, multicenter cohorts, prospective study designs, and integration of both radiographic and clinical outcome measures will be crucial to validate and expand upon these finding\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are thankful to all the participants who sincerely helped us with this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding information\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConflict of interest statement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare no conflicts of interest in this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthical approval and informed consent\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInstitutional ethical approval was achieved with ethical letter number (20180001473h\u003cstrong\u003e)\u003c/strong\u003e and informed consent was waived\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData availability statement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData used in this study will be available on reasonable demand through a valid official email from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDeclaration of generative AI and AI-assisted technologies in the writing\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have used Grammarly tool during the writing of this article to improve the language and they have reviewed and edited the manuscript and they are fully responsible for the content of the published article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBezalel T., Carmeli E., Been E., Kalichman L. (2014). Scheuermann\u0026apos;s disease: current diagnosis and treatment approach. \u003cem\u003eJournal of Back and Musculoskeletal Rehabilitation\u003c/em\u003e, 27(4), 383\u0026ndash;390.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Donnell J.M., Wu W., Youn A., Mann A. and Swarup I., (2023). Scheuermann kyphosis: current concepts and management. \u003cem\u003eCurrent Reviews in Musculoskeletal Medicine\u003c/em\u003e, 16(11), 521\u0026ndash;530.\u003c/li\u003e\n\u003cli\u003eAbousayed M., Elmiligui Y., Elhawary Y., ElNagar A., Elbromboly Y., (2024). The effectiveness of a low implant density in Scheurmann kyphosis in correcting the lumbar lordosis-pelvic incidence mismatch. \u003cem\u003eThe Egyptian Orthopaedic Journal\u003c/em\u003e, 59(3), 311\u0026ndash;316. http://doi:10.4103/eoj.eoj_67_24.\u003c/li\u003e\n\u003cli\u003eChang-Hyun L., Young I.W., Young S.K. \u003cem\u003eet al.\u003c/em\u003e (2021). Posterior-only versus combined anterior-posterior fusion in Scheuermann disease: a systematic review and meta-analysis. \u003cem\u003eJ. Neurosurg Spine\u003c/em\u003e, 34, 608\u0026ndash;616. https://doi.org/10.3171/2020.7.SPINE201062.\u003c/li\u003e\n\u003cli\u003eJoana P., Ana S.E., Pedro R., Jos\u0026eacute; M., Helder N., Jorge A. (2021). Adult scheuermann kyphosis surgical treatment by single posterior approach. \u003cem\u003eJournal of Spine Research and Surgery\u003c/em\u003e, 3(3), 091\u0026ndash;098. DOI:10.26502/fjsrs0033.\u003c/li\u003e\n\u003cli\u003eTom\u0026eacute;-Bermejo F., Tsirikos A.I. (2012). Current concepts on Scheuermann kyphosis: Clinical presentation, diagnosis and controversies around treatment. \u003cem\u003eRevista Espa\u0026ntilde;ola de Cirug\u0026iacute;a Ortop\u0026eacute;dica y Traumatolog\u0026iacute;a\u003c/em\u003e, 56, 491\u0026ndash;505. http://doi:10.1016/j.recote.2012.10.002.\u003c/li\u003e\n\u003cli\u003eSardar Z.M., Ames R.J., Lenke L. (2019). Scheuermannʼs kyphosis: diagnosis, management, and selecting fusion levels. \u003cem\u003eJAAOS-Journal of the American Academy of Orthopaedic Surgeons\u003c/em\u003e, 27(10), e462\u0026ndash;e472. http://doi:10.5435/JAAOS-D-17-00748.\u003c/li\u003e\n\u003cli\u003eSebaaly A., Farjallah S., Kharrat K., Kreichati G., Daher M. (2022). Scheuermann\u0026apos;s kyphosis: update on pathophysiology and surgical treatment. \u003cem\u003eEFORT Open Reviews\u003c/em\u003e, 7(11), 782\u0026ndash;791. https://doi.org/10.1530/EOR-22-0063\u003c/li\u003e\n\u003cli\u003eNasto, L. A., Paolicelli, C., Sieczak, A., Ulisse, P., Cattolico, A., \u0026amp; Pola, E. (2025). Patient-Specific Rods vs Traditional Rods in Surgical Correction of Adult Spinal Deformities: A Case-Matched Study. \u003cem\u003eAnnali Italiani di Chirurgia\u003c/em\u003e, \u003cem\u003e96\u003c/em\u003e(1), 116-123.\u003c/li\u003e\n\u003cli\u003eHollyer I., Johnson T.R., Kha S.T. \u003cem\u003eet al.\u003c/em\u003e (2023). Introduction of a novel sequential approach to the ponte osteotomy to minimize spinal canal exposure.\u003cem\u003e Children\u003c/em\u003e, 10(3), 470. http://doi.org/10.3390/children10030470.\u003c/li\u003e\n\u003cli\u003eTemponi E.F., de Macedo R.D., Pedrosa L.O., Fontes B.P. (2015). Scheuermann\u0026apos;s kyphosis: comparison between the posterior approach associated with Smith-Petersen osteotomy and combined anterior-posterior fusion.\u003cem\u003e \u003c/em\u003e\u003cem\u003eRevista Brasileira De Ortopedia\u003c/em\u003e, 46, 709\u0026ndash;717. https://doi.org/10.1016/S2255-4971(15)30329-3.\u003c/li\u003e\n\u003cli\u003eChady O., Lynn P., Ren\u0026eacute; M.C., Ralph J.B.S., Carmen L.A.V.L. (2025). Early evaluation and treatment of thoracolumbar kyphosis in children with achondroplasia. European Spine Journal, 34, 1221\u0026ndash;1228. https://doi.org/10.1007/s00586-025-08692-5.\u003c/li\u003e\n\u003cli\u003eChen Z., Rong L. (2016). Comparison of combined anterior-posterior approach versus posterior-only approach in treating adolescent idiopathic scoliosis: a meta-analysis. \u003cem\u003eEuropean Spine Journal\u003c/em\u003e, 25(2), 363\u0026ndash;371.\u003c/li\u003e\n\u003cli\u003eZhang H.Q., Wang Y.X., Guo C.F. \u003cem\u003eet al.\u003c/em\u003e (2011). Posterior-only surgery with strong halo-femoral traction for the treatment of adolescent idiopathic scoliotic curves more than 100\u0026deg;.\u003cem\u003e International Orthopaedics\u003c/em\u003e, 35(7), 1037\u0026ndash;1042.\u003c/li\u003e\n\u003cli\u003eShen F., Zhou B., Li Q. \u003cem\u003eet al.\u003c/em\u003e (2015). Posterior-only spinal release combined with derotation, translation, segmental correction, and an in-situ rod-contouring technique for treatment of severe and rigid scoliosis.\u003cem\u003e Journal of Neurosurgery: Spine\u003c/em\u003e, 22(2), 194\u0026ndash;198.\u003c/li\u003e\n\u003cli\u003eNasto L.A., Mousavi Nasab S.H., Sieczak A., Cattolico A., Ulisse P., Pola E. (2024). Ponte osteotomies for treatment of spinal deformities: they are not all made equal. \u003cem\u003eEuropean Spine Journal\u003c/em\u003e, 33(7), 2787\u0026ndash;2793. http://doi.org/10.1007/s00586-024-08334-2.\u003c/li\u003e\n\u003cli\u003eHuq S., Ehresman J., Cottrill E., Ahmed A.K., Pennington Z., Westbroek E.M., Sciubba D.M. (2020). Treatment approaches for Scheuermann kyphosis: a systematic review of historic and current management. \u003cem\u003eJournal of Neurosurgery: Spine\u003c/em\u003e, 32(2), 235\u0026ndash;247. https://doi.org/10.3171/2019.8.SPINE19500.\u003c/li\u003e\n\u003cli\u003eAdem C., Akif A., Yalkin C., Hakan S., Temel T., Mehmet A.K. (2017). Posterior-only approach with pedicle screws for the correction of Scheuermann\u0026apos;s kyphosis. \u003cem\u003eAsian Spine Journal\u003c/em\u003e, 11(4), 513\u0026ndash;519. https://doi.org/10.4184/asj.2017.11.4.513.\u003c/li\u003e\n\u003cli\u003eCho K.J., Lenke L.G., Bridwell K.H., Kamiya M., Sides B. (2009). Selection of the optimal distal fusion level in posterior instrumentation and fusion for thoracic hyperkyphosis: the sagittal stable vertebra concept. \u003cem\u003eSpine\u003c/em\u003e, 34(8), 765\u0026ndash;770.\u003c/li\u003e\n\u003cli\u003eKira F.S., Kenneth R.K., Kenneth D.I., Lindsay M.A., David L.S. (2021). Master\u0026rsquo;s Surgical Technique: Operative Treatment of Scheuermann\u0026rsquo;s Kyphosis. \u003cem\u003eJournal of the Pediatric Orthopaedic Society of North America\u003c/em\u003e, 3(1), 222. https://doi.org/10.55275/JPOSNA-2021-222.\u003c/li\u003e\n\u003cli\u003eQingshan Li. (2021). Surgical Procedures Used for Correction of Scheuermann\u0026rsquo;s Kyphosis: A Meta-Analysis. \u003cem\u003ePain Research and Management\u003c/em\u003e, 2021(1), 2142964. https://doi.org/10.1155/2021/2142964\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Scheuermann’s Kyphosis, Ponte Osteotomy, Spinal Deformity Correction, Thoracic Kyphosis, Sagittal Alignment, Posterior Spinal Fusion","lastPublishedDoi":"10.21203/rs.3.rs-6686863/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6686863/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e Scheuermann's kyphosis is a structural spinal deformity that typically develops before puberty, affecting the thoracic or thoracolumbar spine. Ponte osteotomy is a widely used surgical technique for multiplanar correction of this condition. This study aims to evaluate the radiographic outcomes and effectiveness of Ponte osteotomies in the surgical treatment of Scheuermann’s kyphosis, and to determine the optimal spinal levels for osteotomy to achieve ideal sagittal alignment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A retrospective review was conducted on 63 patients who underwent Ponte osteotomies combined with posterior spinal fusion for the correction of Scheuermann’s kyphosis between 2018 and 2022. Radiographic parameters including thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), and pelvic incidence–lumbar lordosis mismatch (PI–LL), were measured preoperatively, postoperatively, and at a two-year follow-up. The number and location of Ponte osteotomies were analyzed in relation to the degree of correction achieved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The study included 63 patients (42% male, 58% female), with a mean age of 20.4 years. The mean TK was significantly reduced from 78.52° ± 6.47° preoperatively to 44.67° ± 4.98° postoperatively (p \u0026lt; 0.001), with correction maintained at follow-up. Significant improvements were also observed in lumbar lordosis (LL) and the pelvic incidence–lumbar lordosis mismatch (PI–LL). The greatest angular corrections were achieved at the T9–T10 and T10–T11 levels. Intervertebral disc height analysis revealed consistent anterior disc opening, stable central height, and decreased posterior disc height postoperatively. No statistically significant correlation was found between anterior disc height increase and Cobb angle correction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003ePonte osteotomies are effective in achieving and maintaining significant TK correction in patients with Scheuermann’s disease. Optimal sagittal alignment is best achieved by targeting the osteotomies at the apical region and adjacent levels, with a relatively low rate of complications.\u003c/p\u003e","manuscriptTitle":"Efficacy of Ponte Osteotomies in the Surgical Treatment of Scheuermann's Disease: An Analysis of Optimal Spinal Levels for Correction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-03 07:31:37","doi":"10.21203/rs.3.rs-6686863/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ec8cff88-54ac-4fd0-9f28-ef15fd0eac3d","owner":[],"postedDate":"June 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-06T22:23:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-03 07:31:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6686863","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6686863","identity":"rs-6686863","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}