BACKGROUND: Fixed sagittal imbalance (a syndrome in which the patient is only able to stand with the weight-bearing line in front of the sacrum) has many etiologies. The most commonly reported technique for correction is the Smith-Petersen osteotomy. Few reports on pedicle subtraction procedures (resection of the posterior elements, pedicles, and vertebral body through a posterior approach) are available in the peer-reviewed literature. We are aware of no report involving a substantial number of patients with coexistent scoliosis who underwent pedicle/vertebral body subtraction for the treatment of fixed sagittal imbalance. METHODS: Twenty-seven consecutive patients in whom sagittal imbalance was treated with lumbar pedicle subtraction osteotomy at one institution were analyzed. Radiographic analysis included assessment of thoracic kyphosis, lumbar lordosis, lordosis through the pedicle subtraction osteotomy site, and the C7 sagittal plumb line. Outcomes analysis was performed with use of a before-and-after pain scale, items from the Oswestry questionnaire, and the Scoliosis Research Society (SRS) questionnaire after a minimum duration of follow-up of two years. Complications and radiographic findings were also analyzed for the entire group. RESULTS: Overall, the average increase in lordosis was 34.1° and the average improvement in the sagittal plumb line was 13.5 cm. One patient had development of a lumbar pseudarthrosis through the area of pedicle subtraction osteotomy, and six patients had development of a thoracic pseudarthrosis. Two patients had development of increased kyphosis at L5/S1, caudad to the fusion, resulting in some loss of sagittal correction. There were significant improvements in the overall Oswestry score (p < 0.0001) and the pain-scale score (p = 0.0002). Most patients reported improvement in terms of pain and self-image as well as overall satisfaction with the procedure. CONCLUSIONS: Pedicle subtraction osteotomy is a useful procedure for patients with fixed sagittal imbalance. A worse clinical result is associated with increasing patient comorbidities, pseudarthrosis in the thoracic spine, and subsequent breakdown caudad to the fusion.