The Effects of Global Alignment and Proportionality Scores on Postoperative Outcomes After Adult Spinal Deformity Correction

Peter G. Passias, Oscar Krol, Stephane Owusu-Sarpong, Peter Tretiakov, Lara Passfall, Nicholas Kummer, Fares Ani, Bailey Imbo, Rachel Joujon-Roche, Tyler K. Williamson, Navraj S. Sagoo, Shaleen Vira, Andrew Schoenfeld, Rafael De la Garza Ramos, Muhammad Burhan Janjua, Daniel Sciubba, Bassel G. Diebo, Carl Paulino, Justin Smith, Renaud LafageVirginie Lafage

Research output: Contribution to journalArticlepeer-review


BACKGROUND: Recent studies have suggested achieving global alignment and proportionality (GAP) alignment may influence mechanical complications after adult spinal deformity (ASD) surgery. OBJECTIVE: To investigate the association between the GAP score and mechanical complications after ASD surgery. METHODS: Patients with ASD with at least 5-level fusion to pelvis and minimum 2-year data were included. Multivariate analysis was used to find an association between proportioned (P), GAP-moderately disproportioned, and severely disproportioned (GAP-SD) states and mechanical complications (inclusive of proximal junctional kyphosis [PJK], proximal junctional failure [PJF], and implant-related complications [IC]). Severe sagittal deformity was defined by a "++" in the Scoliosis Research Society (SRS)-Schwab criteria for sagittal vertebral axis or pelvic incidence and lumbar lordosis. RESULTS: Two hundred ninety patients with ASD were included. Controlling for age, Charlson comorbidity index, invasiveness and baseline deformity, and multivariate analysis showed no association of GAP-moderately disproportioned patients with proximal junctional kyphosis, PJF, or IC, while GAP-SD patients showed association with IC (odds ratio [OR]: 1.7, [1.1-3.3]; P = .043). Aligning in GAP-relative pelvic version led to lower likelihood of all 3 mechanical complications (all P < .04). In patients with severe sagittal deformity, GAP-SD was predictive of IC (OR: 2.1, [1.1-4.7]; P = .047), and in patients 70 years and older, GAP-SD was also predictive of PJF development (OR: 2.5, [1.1-14.9]; P = .045), while improving in GAP led to lower likelihood of PJF (OR: 0.2, [0.02-0.8]; P = .023). CONCLUSION: Severely disproportioned in GAP is associated with development of any IC and junctional failure specifically in older patients and those with severe baseline deformity. Therefore, incorporation of patient-specific factors into realignment goals may better strengthen the utility of this novel tool.

Original languageEnglish
Pages (from-to)533-541
Number of pages9
JournalOperative neurosurgery (Hagerstown, Md.)
Issue number5
StatePublished - May 1 2023


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