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Surgical planning to address significant lumbar spine pathology, performed without appreciation of global spinal alignment, may have negative consequences. Our objective was to assess whether the extent of recommended surgery for lumbar pathology would significantly change with the addition of long-cassette standing X-rays.Materials and Methods   This was an international online survey of spine surgeons. A series of 15 cases of lumbar spine pathology was presented with a brief clinical vignette and lumbar imaging (X-rays and MRI/CT). Surgeons were asked to select the most appropriate surgical plan, with five choices, ranging from least aggressive (decompression alone; 1 point) to the most aggressive (upper thoracic to sacrum/ilium fusion ± osteotomies/decompression/interbodies; 5 points). Cases were then reordered and presented with long-cassette standing X-rays and the same surgical planning question. Results were compared based on lumbar imaging only versus addition of long-cassette X-rays. Five cases (control group) had normal global alignment and 10 cases (study group) had global malalignment.Results   A total of 316 surgeons completed the survey, predominantly (63%) from North America and Europe. Specialties included orthopedic surgery (65%) and neurosurgery (34%), 68% completed spine fellowship, and responders had a mean 13.4 years in practice that was a mean of 76% spine and included a mean of 123 fusions per year. For study cases, extent of recommended surgery increased significantly with the addition of long-cassette X-rays versus lumbar imaging only ( p = 0.002). For control cases with normal global alignment, no significant changes in surgery plans were identified with the addition of long-cassette X-rays ( p = 0.280).Conclusion   Long-cassette standing X-rays can have a significant impact on surgical planning for lumbar pathology. Surgeons should maintain a relatively low threshold for obtaining long-cassette standing X-rays when contemplating surgical treatment for significant lumbar spine pathology.

Assessment of Impact of Long-Cassette Standing X-rays on Surgical Planning for Lumbar Pathology: An International Survey of Spine Surgeons