{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,6]],"date-time":"2026-06-06T09:01:33Z","timestamp":1780736493350,"version":"3.54.1"},"reference-count":44,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,6,1]]},"abstract":"\n OBJECTIVE<\/jats:title>\n Existing literature on the impact of alignment parameters relative to the thoracolumbar inflection point remains sparse. The authors aimed to investigate the influence of the inflection point, lumbar lordosis apex (LLA), and other alignment parameters on complications, reoperations, and clinical outcomes.<\/jats:p>\n <\/jats:sec>\n \n METHODS<\/jats:title>\n Patients with adult spinal deformity who underwent fusion of the lower thoracic spine (T7\u201312) to pelvis, for whom 2-year data were available, were included. Parameters relative to the inflection point, the inflection point from the upper instrumented vertebra (UIV), the LLA, and the theoretical inflection point based on pelvic incidence in the normative populations from Roussouly morphology were assessed. Patients were evaluated based on inflection point changes of at least 1 level from baseline and stratified into caudal, same, and cranial groups. The analysis controlled for invasiveness, baseline deformity, frailty, and PJK prophylaxis.<\/jats:p>\n <\/jats:sec>\n \n RESULTS<\/jats:title>\n A total of 435 patients (mean age \u00b1 SD 65 \u00b1 8 years) were included in the study. The mean baseline inflection point was at the L1\u20132 interbody space, which was corrected more cranial to the L1 body after surgery. Development of proximal junctional failure (PJF) or proximal junctional kyphosis (PJK) with reoperation was associated with a more caudal baseline inflection point (L2 inferior endplate vs L1 body, p < 0.001). In the adjusted analysis, patients with a more caudal baseline inflection point had 25% higher odds of developing PJF by 2 years (OR 1.26 [95% CI 1.08\u20131.46], p = 0.003). Postoperative normalization to the theoretical Roussouly inflection point had decreased rates of rod breakage (4.5% vs 9.3%, p = 0.049) but higher rates of PJF (13.1% vs 7.7%, p = 0.044). Stratifying patients based on inflection point change from baseline, rates of PJK and PJF 2 years after surgery were higher in the cranial group (both p < 0.003), with no difference in meeting the Roussouly target inflection point. Compared with the cranial group, there was 4.4 times lower odds of developing PJF in the caudal group and 2.0 times lower odds in the group with the same inflection point (p < 0.05). Increased distance from the UIV to the inflection point was associated with mechanical complications (MCs) (p < 0.05). Decreased distance between the LLA and inflection point at baseline was associated with MC (p = 0.04).<\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS<\/jats:title>\n Although correction of the inflection point to normative values decreased rates of MC, PJK rates remain high suggesting other factors being at play. These correlations between the inflection point and the UIV and LLA underscore the pivotal role of the inflection point in achieving adequate realignment.<\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/2025.3.focus24651","type":"journal-article","created":{"date-parts":[[2025,6,1]],"date-time":"2025-06-01T05:55:33Z","timestamp":1748757333000},"page":"E8","source":"Crossref","is-referenced-by-count":1,"title":["Impact of thoracolumbar inflection point on outcomes and complications in adult spinal deformity"],"prefix":"10.3171","volume":"58","author":[{"given":"Jamshaid M.","family":"Mir","sequence":"first","affiliation":[{"name":"Division of Spine Surgery, Departments of Orthopedic and Neurological Surgery, Duke University Medical Center, Durham, North Carolina;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Justin S.","family":"Smith","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Virginia, Charlottesville, Virginia;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anthony","family":"Yung","sequence":"additional","affiliation":[{"name":"Division of Spine Surgery, Departments of Orthopedic and Neurological Surgery, Duke University Medical Center, Durham, North Carolina;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Oluwatobi O.","family":"Onafowokan","sequence":"additional","affiliation":[{"name":"Division of Spine Surgery, Departments of Orthopedic and Neurological Surgery, Duke University Medical Center, Durham, North Carolina;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Renaud","family":"Lafage","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeffrey","family":"Gum","sequence":"additional","affiliation":[{"name":"Norton Leatherman Spine Center, Louisville, Kentucky;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Breton G.","family":"Line","sequence":"additional","affiliation":[{"name":"Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke\u2019s\/Rocky Mountain Hospital for Children, Denver, Colorado;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bassel","family":"Diebo","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alan H.","family":"Daniels","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"D. Kojo","family":"Hamilton","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of Pittsburgh, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nitin","family":"Agarwal","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of Pittsburgh, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas J.","family":"Buell","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of Pittsburgh, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Justin K.","family":"Scheer","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Columbia University, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert K.","family":"Eastlack","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeffrey P.","family":"Mullin","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University at Buffalo, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gregory M.","family":"Mundis","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Naobumi","family":"Hosogane","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Kyorin University School of Medicine, Tokyo, Japan;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mitsuru","family":"Yagi","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, School of Medicine, International University of Health and Welfare, Chiba, Japan;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Neel","family":"Anand","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Praveen V.","family":"Mummaneni","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, University of California, San Francisco, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dean","family":"Chou","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Columbia University, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric O.","family":"Klineberg","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, University of California, Davis, Sacramento, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Khaled M.","family":"Kebaish","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Munish C.","family":"Gupta","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Washington University, St. Louis, Missouri;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Han Jo","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Hospital for Special Surgery, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lawrence G.","family":"Lenke","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, The Och Spine Hospital\/Columbia University Irving Medical Center, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher P.","family":"Ames","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, University of California, San Francisco, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frank J.","family":"Schwab","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Virginie","family":"Lafage","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard A.","family":"Hostin","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Southwest Scoliosis Institute, Dallas, Texas; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shay","family":"Bess","sequence":"additional","affiliation":[{"name":"Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke\u2019s\/Rocky Mountain Hospital for Children, Denver, Colorado;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Douglas C.","family":"Burton","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher I.","family":"Shaffrey","sequence":"additional","affiliation":[{"name":"Division of Spine Surgery, Departments of Orthopedic and Neurological Surgery, Duke University Medical Center, Durham, North Carolina;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter G.","family":"Passias","sequence":"additional","affiliation":[{"name":"Division of Spine Surgery, Departments of Orthopedic and Neurological Surgery, Duke University Medical Center, Durham, North Carolina;"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"4","key":"b1","series-title":"Spine Deform","first-page":"265","article-title":"A critical analysis of sagittal plane deformity correction with minimally invasive adult spinal deformity surgery: a 2-year follow-up study","volume":"5","author":"Mundis GM Jr","year":"2017","unstructured":"Mundis GM Jr, Turner JD, Deverin V, A critical analysis of sagittal plane deformity correction with minimally invasive adult spinal deformity surgery: a 2-year follow-up study. 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Spine (Phila Pa 1976). 2005;30(6):682\u2013688."},{"issue":"3","key":"b4","series-title":"Spine (Phila Pa 1976)","first-page":"346","article-title":"Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position","volume":"30","author":"Roussouly P","year":"2005","unstructured":"Roussouly P, Gollogly S, Berthonnaud E, Dimnet J. Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine (Phila Pa 1976). 2005;30(3):346\u2013353."},{"issue":"5","key":"b5","series-title":"J Chronic Dis","first-page":"373","article-title":"A new method of classifying prognostic comorbidity in longitudinal studies: development and validation","volume":"40","author":"Charlson ME","year":"1987","unstructured":"Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. 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J Craniovertebr Junction Spine. 2024;15(3):347\u2013352."},{"key":"b21","series-title":"Published online December","article-title":"Single-position prone lateral interbody fusion is associated with improved radiographic and clinical outcomes at one year compared to single-position lateral interbody fusion: a single institution experience. Spine (Phila Pa 1976)","volume":"16,","author":"Yung A","year":"2024","unstructured":"Yung A, Onafowokan OO, Tretiakov PS, Single-position prone lateral interbody fusion is associated with improved radiographic and clinical outcomes at one year compared to single-position lateral interbody fusion: a single institution experience. Spine (Phila Pa 1976). 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Spine Deform. 2023;11(4):773\u2013785."},{"issue":"6","key":"b3","series-title":"Spine (Phila Pa 1976)","first-page":"682","article-title":"Correlation of radiographic parameters and clinical symptoms in adult scoliosis","volume":"30","author":"Glassman SD","year":"2005","unstructured":"Glassman SD, Berven S, Bridwell K, Horton W, Dimar JR. Correlation of radiographic parameters and clinical symptoms in adult scoliosis. Spine (Phila Pa 1976). 2005;30(6):682\u2013688."},{"issue":"3","key":"b4","series-title":"Spine (Phila Pa 1976)","first-page":"346","article-title":"Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position","volume":"30","author":"Roussouly P","year":"2005","unstructured":"Roussouly P, Gollogly S, Berthonnaud E, Dimnet J. Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. 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Int J Spine Surg. 2020;14(6):1031\u20131036."},{"issue":"20","key":"b7","series-title":"Spine (Phila Pa 1976)","first-page":"1463","article-title":"Performance of the modified Adult Spinal Deformity frailty index in preoperative risk assessment","volume":"47","author":"Passias PG","year":"2022","unstructured":"Passias PG, Moattari K, Pierce KE, Performance of the modified Adult Spinal Deformity frailty index in preoperative risk assessment. Spine (Phila Pa 1976). 2022;47(20):1463\u20131469."},{"issue":"1","key":"b8","series-title":"Spine Deform","first-page":"121","article-title":"Sagittal age-adjusted score (SAAS) for adult spinal deformity (ASD) more effectively predicts surgical outcomes and proximal junctional kyphosis than previous classifications","volume":"10","author":"Lafage R","year":"2022","unstructured":"Lafage R, Smith JS, Elysee J, Sagittal age-adjusted score (SAAS) for adult spinal deformity (ASD) more effectively predicts surgical outcomes and proximal junctional kyphosis than previous classifications. Spine Deform. 2022;10(1):121\u2013131."},{"issue":"19","key":"b9","series-title":"J Bone Joint Surg Am","first-page":"1661","article-title":"Global Alignment and Proportion (GAP) Score: development and validation of a new method of analyzing spinopelvic alignment to predict mechanical complications after adult spinal deformity surgery","volume":"99","author":"Yilgor C","year":"2017","unstructured":"Yilgor C, Sogunmez N, Boissiere L, Global Alignment and Proportion (GAP) Score: development and validation of a new method of analyzing spinopelvic alignment to predict mechanical complications after adult spinal deformity surgery. J Bone Joint Surg Am. 2017;99(19):1661\u20131672."},{"issue":"5","key":"b10","series-title":"J Neurosurg Spine","first-page":"593","article-title":"Lordosis distribution index for predicting mechanical complications after long-level fusion surgery: comparison of Global Alignment and Proportion score and Roussouly classification","volume":"40","author":"Moon MH","year":"2024","unstructured":"Moon MH, Shin MH, Yoo SC, Choi DY, Kim JT. Lordosis distribution index for predicting mechanical complications after long-level fusion surgery: comparison of Global Alignment and Proportion score and Roussouly classification. J Neurosurg Spine. 2024;40(5):593\u2013601."},{"issue":"3","key":"b11","series-title":"Spine Deform","first-page":"491","article-title":"Ideal sagittal profile restoration and ideal lumbar apex positioning play an important role in postoperative mechanical complications after a lumbar PSO","volume":"8","author":"Pizones J","year":"2020","unstructured":"Pizones J, Perez-Grueso FJS, Moreno-Manzanaro L, Ideal sagittal profile restoration and ideal lumbar apex positioning play an important role in postoperative mechanical complications after a lumbar PSO. Spine Deform. 2020;8(3):491\u2013498."},{"issue":"14","key":"b12","series-title":"Spine (Phila Pa 1976)","first-page":"1643","article-title":"Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis","volume":"30","author":"Glattes RC","year":"2005","unstructured":"Glattes RC, Bridwell KH, Lenke LG, Kim YJ, Rinella A, Edwards C. 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