• Management and Risk Factors of Fracture-Type Proximal Junctional Kyphosis: Focus on Myelopathy and Intervention
• Optimizing Rod Configuration Across Lumbar Pedicle Subtraction Osteotomy Site: Evolution of a High-Volume Deformity Practice
• Minimally Invasive Surgery in Adult Spinal Deformity and the Future
• Osteoporosis in Adult Patients Undergoing Spinal Reconstructive Surgery: Associated Complications and Management
• The Association Between Comorbidities and Medical Complications for Adult Spinal Deformity Surgery: What Factors Have the Greatest Impact on Adverse Events and Outcomes?
• Perioperative Medical Complications in Adult Spine Deformity Surgery: Classification and Prevention Strategies
• Alignment Goals in Adult Spinal Deformity Surgery
• Determining the Magnitude of Surgery in Patients With Adult Scoliosis: A Systematic Review of the Role of Limited Fusions

In a narrative review Pizones et al. from La Paz Univ. Hosp, Madrid; additional centers in San Antonio, San Diego, Toronto, Barcelona, Charlottesville, New York published in the Global Spine Journal to critically examine evolving strategies in sagittal alignment targets for adult spinal deformity surgery, shifting focus from generic HRQoL goals to preventing mechanical complications Traditional alignment metrics (PI‑LL, SVA, TK) are limited for personalized planning; compensatory strategies (pelvic retroversion, knee flexion) are essential; individualized, structure-shape–based alignment (e.g., GAP, Roussouly, T4‑L1‑Hip‑Axis) reduces mechanical failure risk, though reoperation rates remain high ¹⁾.

The narrative review offers a comprehensive appraisal of alignment paradigms, yet:

* Strengths: Integrates key classification systems; emphasizes pelvic and lower-extremity compensation; aligns recent evidence on shape-based vs. quality-of-life–based targets; timely discussion given recent advances (e.g., T4‑L1‑Hip‑Axis)

* Weaknesses: Lacks systematic methodology or quantitative synthesis; conclusions primarily descriptive; limited critical appraisal of conflicting literature; evidence grade unclear

* Evidence gaps: No robust meta-analysis to support superiority of new alignment strategies; minimal discussion on age-adjusted goals (e.g., Lafage et al., 2016, 2017) and their clinical endpoints

The article is a well-informed narrative but falls short of high-level evidence. It’s hypothesis-generating rather than definitive in guiding surgical decision-making.

Rating: 6/10

Use alignment strategies that respect patient-specific morphology (like GAP and Roussouly) and consider whole-body compensation. However, be cautious—this guidance is based on emerging concepts, not on strong comparative trials or comprehensive outcomes data.

An informative review on evolving alignment goals—but lacking in solid evidence. A step forward in concept, yet insufficient as a standalone clinical guide until validated by robust comparative studies.

Alignment Goals in Adult Spinal Deformity Surgery. Pizones J et al. *Global Spine J.* 2025 Jul;15(3_suppl):108S‑122S. doi:10.1177/21925682251331048. Published July 9, 2025. Corresponding author: Javier Pizones, Spine Surgery Unit, La Paz University Hospital, Madrid, Spain.

Adult spinal deformity surgery is a specialized surgical procedure aimed at correcting abnormal curvatures and alignment of the spine in adults. These deformities can result from various conditions, including degenerative changes, scoliosis, kyphosis, or a combination of factors. The primary goals of adult spinal deformity surgery are to alleviate pain, improve spinal alignment, restore function, and enhance the patient's quality of life.

Before surgery, a comprehensive evaluation is conducted, including a detailed medical history, physical examination, imaging studies (such as X-rays, MRI, and CT scans), and assessment of pain, mobility, and neurological function. This evaluation helps determine the extent and nature of the deformity and guides treatment decisions.

Frailty-based prehabilitation for patients undergoing spinal deformity surgery ²⁾

Adult spinal deformity surgery is reserved for a small subset of patients who have failed all reasonable conservative (non-operative) measures. They generally have disabling back and/or leg pain and spinal imbalance. Their functional activities are severely restricted and their overall quality of life has been reduced substantially.

Sagittal spinopelvic alignment varies with age. Thus, operative realignment targets should account for age, with younger patients requiring more rigorous alignment objectives ³⁾

The goals of surgery are to restore spinal balance and reduce pain and discomfort by relieving pressure off the nerves (decompression) and maintaining corrected alignment by fusing and stabilizing the spinal segments. Surgical stabilization involves anchoring hooks, wires or screws to the spinal segments and using metal rods to link the anchors together. They act as a tether and allow the spine to fuse in the corrected position. Fusion is performed by using the patient’s own bone or using a cadaver or synthetic bone substitutes. In more severe cases, spinal segments have to be cut and realigned (osteotomy) or entire segments may have to be removed prior to realigning the spine (vertebral column resection). There are many different types of surgical procedures designed to treat adult spinal deformities. A detailed description of each is beyond the scope of this discussion.

It is important to note that surgery in the adult deformity population is riskier than in the adolescent teenager. The complication rate is significantly higher and the recovery is a lot slower. Therefore, surgery should only be undertaken as a last resort and only after the patient has a clear understanding of the risks and benefits. All reasonable non-surgical measures should be attempted first. At the same time, when patients are carefully chosen and are mentally well-prepared for the surgery, excellent functional outcomes can be obtained which at times can be a positive life-changing experience for a given individual patient.

Recent advances in surgical techniques include less invasive approaches by making smaller incisions as well as using biological substances to accelerate the fusion process. The use of computer-assisted navigation systems and various forms of the spinal cord and nerve monitoring may help in improving surgical precision and accuracy. Although promising, longer follow-ups are needed before one can conclude that they are superior to existing time-honored methods.

Adult spinal deformity surgery involves various surgical approaches, which may include:

Decompression: Removing pressure on spinal nerves or the spinal cord.

Fusion: Joining vertebrae together to stabilize the spine.

Osteotomies: Surgical cuts in the bone to correct deformities and restore proper alignment.

Instrumentation: The use of implants (such as screws, rods, and cages) to support and stabilize the spine.

Minimally invasive surgery for adult spinal deformity.

Minimally invasive surgery (MIS) is an alternative to open deformity surgery for the treatment of patients with adult spinal deformity. However, at this time MIS techniques are not as versatile as open deformity techniques, and MIS techniques have been reported to result in suboptimal sagittal plane correction or pseudarthrosis when used for severe deformities. The minimally invasive spinal deformity surgery (MISDEF) algorithm was created to provide a framework for rational decision making for surgeons who are considering MIS versus open spine surgery.

Methods: A team of experienced spinal deformity surgeons developed the MISDEF algorithm that incorporates a patient's preoperative radiographic parameters and leads to one of 3 general plans ranging from MIS direct or indirect decompression to open deformity surgery with osteotomies. The authors surveyed fellowship-trained spine surgeons experienced with spinal deformity surgery to validate the algorithm using a set of 20 cases to establish interobserver reliability. They then resurveyed the same surgeons 2 months later with the same cases presented in a different sequence to establish intraobserver reliability. Responses were collected and tabulated. Fleiss' analysis was performed using MATLAB software.

Results: Over a 3-month period, 11 surgeons completed the surveys. Responses for MISDEF algorithm case review demonstrated an interobserver kappa of 0.58 for the first round of surveys and an interobserver kappa of 0.69 for the second round of surveys, consistent with the substantial agreement. In at least 10 cases there was perfect agreement between the reviewing surgeons. The mean intraobserver kappa for the 2 surveys was 0.86 ± 0.15 (± SD) and ranged from 0.62 to 1.

The use of the MISDEF algorithm provides consistent and straightforward guidance for surgeons who are considering either an MIS or an open approach for the treatment of patients with adult spinal deformities. The MISDEF algorithm was found to have a substantial inter- and intraobserver agreement. Although further studies are needed, the application of this algorithm could provide a platform for surgeons to achieve the desired goals of surgery ⁴⁾.

After surgery, patients undergo a period of recovery and rehabilitation. This may involve wearing a brace, physical therapy, and gradually returning to normal activities. The length of recovery can vary based on the complexity of the surgery and the patient's overall health.

Acute needs must be considered following Adult Spinal Deformity surgery, however, matched analysis comparing 30-day hospital readmissions, 90-day return to surgery, postoperative complications, and patient-reported outcomes demonstrated minimal benefit for NON, REHAB, or skilled nursing facility (SNF) versus HOME at 1-year and 2-year follow-up, questioning the risk and cost/benefits of routine use of non-home discharge ⁵⁾.

Adult spinal deformity surgery complications.

Adult spinal deformity surgery outcome.