• KumarRohit PremRP0009-0003-4657-2864Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA., Samuel Adida, Raj Swaroop Lavadi, Rida Mitha, Andrew D Legarreta, Joseph S Hudson, Manan Shah, Bassel Diebo, Daryl P Fields, Thomas J Buell, D Kojo Hamilton, Alan H Daniels, and Nitin Agarwal.
• Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
• Eur Spine J. 2024 Jul 1; 33 (7): 274227502742-2750.

PurposeOperative treatment of adult spinal deformity (ASD) has been shown to improve patient health-related quality of life (HRQOL). Selection of the uppermost instrumented vertebra (UIV) in either the upper thoracic (UT) or lower thoracic (LT) spine is a pivotal decision with effects on operative and postoperative outcomes. This review overviews the multifaceted decision-making process for UIV selection in ASD correction.MethodsPubMed was queried for articles using the keywords "uppermost instrumented vertebra", "upper thoracic", "lower thoracic", and "adult spinal deformity".ResultsOptimization of UIV selection may lead to superior deformity correction, better patient-reported outcomes, and lower risk of proximal junctional kyphosis (PJK) and failure (PJF). Patient alignment characteristics, including preoperative thoracic kyphosis, coronal deformity, and the magnitude of sagittal correction influence surgical decision-making when selecting a UIV, while comorbidities such as poor body mass index, osteoporosis, and neuromuscular pathology should also be taken in to account. Additionally, surgeon experience and resources available to the hospital may also play a role in this decision. Currently, it is incompletely understood whether postoperative HRQOLs, functional and radiographic outcomes, and complications after surgery differ between selection of the UIV in either the UT or LT spine.ConclusionThe correct selection of the UIV in surgical planning is a challenging task, which requires attention to preoperative alignment, patient comorbidities, clinical characteristics, available resources, and surgeon-specific factors such as experience.© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.

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