82 year old female had prior fusion surgery 8 years ago elsewhere. Over the last few years she had developed worsening flatback deformity and sagittal imbalance. She walked leaning forward and could not stand upright. She had severe low back pain and pain and numbness in her legs as a result of stenosis at the level above the fusion. She underwent a one stage reconstruction, consisting of revision laminectomies, pedicle subtraction osteotomy at L3 and correction of her deformity. Because of her osteoporosis, cement was used to strengthen the fixation of screws in her lumbar spine.