• Riccardo Raganato, Javier Pizones, Caglar Yilgor, Lucía Moreno-Manzanaro, Alba Vila-Casademunt, José Miguel Sánchez-Márquez, Nicomedes Fernández-Baíllo, Sánchez Pérez-GruesoFrancisco JavierFJSpine Unit, Department of Orthopedic Surgery, Hospital La Paz, Paseo de La Castellana 261, 28046, Madrid, Spain., Frank Kleinstück, Ahmet Alanay, Ibrahim Obeid, Ferran Pellisé, and ESSG European Spine Study Group.
• Spine Unit, Department of Orthopedic Surgery, Hospital La Paz, Paseo de La Castellana 261, 28046, Madrid, Spain.
• Eur Spine J. 2023 Jun 1; 32 (6): 223822472238-2247.

IntroductionThe Global Alignment and Proportion (GAP) score incorporates three domains directly modified with surgery (relative pelvic version-RPV, relative lumbar lordosis-RLL, lumbar distribution index-LDI) and one indirectly restored (relative spinopelvic alignment-RSA). We analyzed our surgical realignment performance and the consequences of domain-specific realignment failure on mechanical complications and PROMs.Materials And MethodsFrom an adult spinal deformity prospective multicenter database, we selected patients: fused to pelvis, upper instrumented vertebra at or above L1, and 2 years of follow-up. Descriptive, univariate and multivariate analyses were employed.ResultsThe sample included 333 patients. RLL-6w showed the highest success rate (58.3% aligned), but 16.5% of patients were classified in the "Severe hypolordosis" and "Hyperlordosis" subgroups. RPV-6w was the most challenging to realign, with 51.6% moderate or severe retroversion. Regarding RSA-6w, 21.9% had severe positive malalignment. Correct alignment of RPV-6w (p = 0.025) and RSA-6w (p = 0.002) proved to be protective factors against the development of mechanical complications. Severe pelvic retroversion (p = 0.026) and severe positive malalignment (p = 0.007) were risk factors for mechanical complications. RSA-6w "Severe positive malalignment" was associated with less improvement in PROMs: ∆ODI (8.83 vs 17.2; p = 0.011), ∆SRS-22 total (0.54 vs 0.87; p = 0.007), and ∆SF-36PCS (3.47 vs 7.76; p = 0.04); MCID for ODI (37.0 vs 55.5%; p = 0.023), and SRS-22 (40.8 vs 60.1%; p = 0.015); and PASS for ODI (17.6 vs 31.7%; p = 0.047).ConclusionsRPV was the most underperformed modifiable parameter. Severe pelvic retroversion and severe positive malalignment influenced the occurrence of mechanical complications. Severe positive malalignment affected PROMs improvement.© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.

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