Adult thoracolumbar kyphosis resulting from osteoporotic vertebral fractures (OVF) severely compromises function and quality of life, and traditional three column osteotomy (3CO), although effective for deformity correction, carries substantial morbidity in elderly patients. This study compared radiographic and clinical outcomes in septuagenarians treated with single-position navigated lateral column realignment with anterior longitudinal ligament release (LCR-A), plus posterior column osteotomy (PCO) and posterior spinal fusion (PSF), or percutaneous pedicle screws (PPS), versus those treated with 3CO. A retrospective review included 21 patients who underwent LCR-A and 54 who underwent 3CO between March 2020 and April 2024. Radiographic parameters, Oswestry Disability Index (ODI), SRS-22 scores, perioperative variables, and complications were evaluated over a 2-year follow-up period.

Despite being older, patients treated with LCR-A experienced significantly less blood loss, shorter operative duration, and fewer fused levels than those undergoing 3CO. LCR-A provided deformity correction comparable to that achieved with 3CO while demonstrating advantages in early recovery and long-term function. Patients in the LCR-A group had lower postoperative ODI scores and superior SRS-22 outcomes, indicating better pain relief, function, and overall satisfaction. Radiographic correction was maintained throughout follow-up, with fewer new neurological deficits and reduced incidence of postoperative complications, including infection, ileus, and delirium. By contrast, the 3CO cohort exhibited higher morbidity, reflecting the physiologic burden associated with extensive posterior column manipulation in older adults.

These findings suggest that single-position navigated LCR-A offers a safer and less invasive alternative to traditional 3CO for elderly patients with thoracolumbar kyphosis secondary to OVF. The technique enables effective sagittal realignment with fewer fused segments, reduced perioperative risk, fewer complications, and superior functional recovery. Incorporating minimally invasive anterior release strategies may provide meaningful clinical benefit and expand treatment options for this high-risk population.