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The human spine is uniquely shaped compared to that of quadrupedal primates. Throughout human evolution, the transition from quadrupedal to bipedal locomotion involved a series of anatomical adaptations in both the spine and pelvis, enabling prolonged upright posture and resulting in the characteristic S-shape of the spine. This balance can be disrupted by degeneration, fractures, neuromuscular disorders, or surgical interventions, potentially leading to adult spinal deformity (ASD). Surgical correction of ASD is associated with a high risk of complications.

This dissertation evaluates the effectiveness of surgical strategies for correcting abnormal sagittal alignment, with a particular focus on various pelvic osteotomies as potentially less invasive alternatives to spinal osteotomy. Chapter 2 presents a systematic literature review involving 973 patients, identifying pelvic tilt as a key radiographic parameter strongly linked to clinical outcomes. Chapter 3 reports on a survey among Dutch spine surgeons, revealing that although sagittal alignment parameters are widely recognized as important, their application in clinical decision-making remains inconsistent, highlighting the need for standardized protocols. Chapter 4 investigates surgical techniques for restoring lumbar lordosis in cadaveric models, demonstrating that bilateral facetectomy achieved the greatest correction. Chapter 5 introduces the bilateral anterior open-wedge pelvic osteotomy (BEPO), which effectively reduces pelvic incidence and may be particularly valuable when lumbar osteotomy alone is insufficient. Chapter 6 compares four pelvic osteotomy techniques using an in-silico model; the dome osteotomy around the acetabulum (A-DPO) was the most predictable but technically demanding, whereas the BEPO was less complex but required more advanced stabilization methods.