Spine Surgeons Go Head-to-Head | IMAST 2026 Debates | Scoliosis Dialogues

Thanks.

Is this mic on? Yeah, thanks so much, John.

And I really appreciate you starting or providing a topic, including the phrase inside you for Steve Lewis.

So you had to actually look it up in the book.

So I'm all about coronal alignment.

And here are my disclosures.

Sorry, is the clicker working? Okay, so just probably to highlight, I do have a provisional patent application for a sagittal contouring system, and so although I might have a financial conflict to throw this debate, my animosity towards Fred Nichols is longstanding and solid, and so that bias is trumped.

Okay.

My premise is quite clear.

Chronal alignment is the primary patient-facing outcome that parents and patients alike find important.

Sagittal plane alignment is important, but it's out of our control primarily.

It has lots of sagittal compensatory mechanisms that account for it and very difficult to assess intraoperatively.

And what my learned colleague to my right and from the prairies is going to try and convince you that our patients are like horses.

And I'm here to tell you that they're not.

It's quite simple biology.

Humans spend most of their time worrying about what's in front of them, unlike horses, Fred, that look mainly at the side.

And so our patients come to us with issues that they see in the mirror.

Asymmetric shoulders, waist asymmetry, chest asymmetry, all coronal plane problems.

And so from the very first interaction until the last, it's a coronal plane problem.

Even our classification systems are hugely biased towards coronal plane abnormalities as demonstrated by the Lanke system.

And our coronal goals are very well established.

We and our patients all agree that shoulders need to be level, waist need to be symmetric, and head needs to be over the pelvis.

In the sagittal plane, we as a profession can't even get it right.

You miss one academic meeting and these sagittal plane ninnies will come up with a completely new way to assess the sagittal alignment.

So if we can't agree on it, how can our patients? And then what am I supposed to do? Should I fuse the patient to 16, future-proofing them as an octogenarian because we know the sagittal plane and alignment changes over time? Or do I give them the best sagittal profile for their age at the moment? Level selection, again, is primarily dominated by coronal plane alignment metrics.