{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T06:16:15Z","timestamp":1788934575599,"version":"build-2803163510"},"reference-count":88,"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":"<jats:sec>\n                    <jats:title>OBJECTIVE<\/jats:title>\n                    <jats:p>Software engineering innovations have led to the development of virtual surgical planning software (VSPS) for deformity correction. VSPS uses calibrated radiographs and machine learning predictive models to simulate postoperative spinopelvic parameters based on corrective techniques and anticipated compensatory\/reciprocal changes. The authors aimed to assess the safety and efficacy of deformity correction in adult spinal deformity using VSPS and patient-specific rods manufactured based on a simulated plan.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS<\/jats:title>\n                    <jats:p>A retrospective analysis of a prospectively maintained database was conducted, and 146 patients who underwent long-segment thoracolumbar fusions with pelvic fixation (October 2015\u2013May 2023) with a minimum of 1 year of follow-up for deformity correction consistent with the Scoliosis Research Society (SRS)\u2013Schwab classification were identified. Patients were dichotomized into a VSPS group (61 patients, mean age 62.1 years) and a historical control group (85 patients, mean age 64.3 years) prior to implementing VSPS. Comparative analyses were performed to assess VSPS accuracy and outcomes. Equivalence analysis was performed via the two one-sided t-test method using Cohen\u2019s d = 0.5.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS<\/jats:title>\n                    <jats:p>In the VSPS group, the achieved spinopelvic parameters at 3 months were equivalent to the simulated plan for lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), sacral slope, PI-LL mismatch, sagittal vertical axis (SVA), T1 pelvic angle (T1PA), thoracic kyphosis, and L4\u2013S1 lordosis. Compared with controls, VSPS demonstrated an increased L4\u2013S1 lordosis (p = 0.001) and decreased T1PA (p = 0.001); L4\u2013S1 lordosis within 4.26\u00b0 (p = 0.989) and T1PA within 3.85\u00b0 (p = 0.969) were not significantly equivalent. VSPS demonstrated a significant increase in achievement of an SVA &lt; 5 cm (p = 0.026), T1PA &lt; 20\u00b0 (p = 0.001), and age-adjusted T1PA (p &lt; 0.001). The age-adjusted PI-LL mismatch (p = 0.018), PT (p = 0.002), and SVA (p = 0.021) were equivalent. There was no significant difference in the improvement of 1-year patient-reported outcome measures (PROMs), proximal junctional kyphosis (p = 0.270), or proximal junctional failure (p = 0.290) between the two groups. In the multivariate analysis, VSPS use independently predicted achievement of age-adjusted T1PA (OR 6.51, p = 0.001). The upper instrumented vertebra, number of rods and rod material, and VSPS were not predictors of complications or reoperation for hardware failure. The time interval from the first surgery was not a predictor of complications or age-adjusted spinopelvic parameters.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS<\/jats:title>\n                    <jats:p>VSPS accurately predicted achieved spinal alignment at 3 months. VSPS has the potential to facilitate global spinopelvic parameter correction, particularly reflected by T1PA and L4\u2013S1 lordosis. However, this study did not demonstrate meaningful improvements in PROMs compared with controls. To justify the increased cost and widespread adoption of this technology in its current state, a clear functional benefit should be demonstrated along with a cost-benefit analysis. Further research is necessary to delineate long-term durability and the potential impact of VSPS and patient-specific instrumentation, particularly with continual software and engineering innovations.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/2025.3.focus259","type":"journal-article","created":{"date-parts":[[2025,6,1]],"date-time":"2025-06-01T05:55:29Z","timestamp":1748757329000},"page":"E11","source":"Crossref","is-referenced-by-count":4,"title":["Early outcomes with virtual surgical planning software and patient-specific instrumentation in adult spinal deformity"],"prefix":"10.3171","volume":"58","author":[{"given":"Joshua H.","family":"Weinberg","sequence":"first","affiliation":[{"name":"Department of Neurosurgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nathan","family":"Ritchey","sequence":"additional","affiliation":[{"name":"College of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joshua L.","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ryan G.","family":"Eaton","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bryan","family":"Ladd","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Siri","family":"Khalsa","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David","family":"Xu","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stephanus","family":"Viljoen","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew","family":"Grossbach","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"6","key":"b1","series-title":"Asian Spine J","first-page":"886","article-title":"Adult spinal deformity: current concepts and decision-making strategies for management","volume":"14","author":"Kim HJ","year":"2020","unstructured":"Kim HJ, Yang JH, Chang DG,  Adult spinal deformity: current concepts and decision-making strategies for management. Asian Spine J. 2020;14(6):886\u2013897."},{"issue":"10193","key":"b2","series-title":"Lancet","first-page":"160","article-title":"Adult spinal deformity","volume":"394","author":"Diebo BG","year":"2019","unstructured":"Diebo BG, Shah NV, Boachie-Adjei O,  Adult spinal deformity. Lancet. 2019;394(10193):160\u2013172."},{"issue":"4","key":"b3","series-title":"Spine Deform","first-page":"310","article-title":"Adult spinal deformity: epidemiology, health impact, evaluation, and management","volume":"4","author":"Ames CP","year":"2016","unstructured":"Ames CP, Scheer JK, Lafage V,  Adult spinal deformity: epidemiology, health impact, evaluation, and management. Spine Deform. 2016;4(4):310\u2013322."},{"issue":"6","key":"b4","series-title":"Spine (Phila Pa 1976)","first-page":"602","article-title":"Adult scoliosis: a health assessment analysis by SF-36","volume":"28","author":"Schwab F","year":"2003","unstructured":"Schwab F, Dubey A, Pagala M, Gamez L, Farcy JP. Adult scoliosis: a health assessment analysis by SF-36. Spine (Phila Pa 1976). 2003;28(6):602\u2013606."},{"issue":"9","key":"b5","series-title":"Spine (Phila Pa 1976)","first-page":"1082","article-title":"Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population","volume":"30","author":"Schwab F","year":"2005","unstructured":"Schwab F, Dubey A, Gamez L,  Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine (Phila Pa 1976). 2005;30(9):1082\u20131085."},{"issue":"1","key":"b6","series-title":"Eur Spine J","first-page":"3","article-title":"Impact on health related quality of life of adult spinal deformity (ASD) compared with other chronic conditions","volume":"24","author":"Pellis\u00e9 F","year":"2015","unstructured":"Pellis\u00e9 F, Vila-Casademunt A, Ferrer M,  Impact on health related quality of life of adult spinal deformity (ASD) compared with other chronic conditions. Eur Spine J. 2015;24(1):3\u201311."},{"issue":"9","key":"b7","series-title":"Spine J","first-page":"S2","article-title":"Health impact comparison of different disease states and population norms to adult spinal deformity (ASD): a call for medical attention","volume":"12","author":"Fu KMG","year":"2012","unstructured":"Fu KMG, Bess RS, Schwab FJ,  Health impact comparison of different disease states and population norms to adult spinal deformity (ASD): a call for medical attention. Spine J. 2012;12(9):S2."},{"issue":"1","key":"b8","series-title":"Neurosurgery","first-page":"86","article-title":"Improvement of back pain with operative and nonoperative treatment in adults with scoliosis","volume":"65","author":"Smith JS","year":"2009","unstructured":"Smith JS, Shaffrey CI, Berven S,  Improvement of back pain with operative and nonoperative treatment in adults with scoliosis. Neurosurgery. 2009;65(1):86\u201394."},{"issue":"6","key":"b9","series-title":"J Neurosurg Spine","first-page":"994","article-title":"Prospective multicenter assessment of risk factors for rod fracture following surgery for adult spinal deformity","volume":"21","author":"Smith JS","year":"2014","unstructured":"Smith JS, Shaffrey E, Klineberg E,  Prospective multicenter assessment of risk factors for rod fracture following surgery for adult spinal deformity. J Neurosurg Spine. 2014;21(6):994\u20131003."},{"issue":"4","key":"b10","series-title":"Neurosurgery","first-page":"862","article-title":"Assessment of symptomatic rod fracture after posterior instrumented fusion for adult spinal deformity","volume":"71","author":"Smith JS","year":"2012","unstructured":"Smith JS, Shaffrey CI, Ames CP,  Assessment of symptomatic rod fracture after posterior instrumented fusion for adult spinal deformity. Neurosurgery. 2012;71(4):862\u2013867."},{"key":"b11","series-title":"World Neurosurg","first-page":"905","article-title":"The fate of patients with adult spinal deformity incurring rod fracture after thoracolumbar fusion","volume":"106","author":"Hamilton DK","year":"2017","unstructured":"Hamilton DK, Buza JA, Passias P,  The fate of patients with adult spinal deformity incurring rod fracture after thoracolumbar fusion. World Neurosurg. 2017;106:905\u2013911."},{"issue":"3","key":"b12","series-title":"Curr Rev Musculoskelet Med","first-page":"299","article-title":"Proximal junctional kyphosis and failure\u2014diagnosis, prevention, and treatment","volume":"9","author":"Nguyen NLM","year":"2016","unstructured":"Nguyen NLM, Kong CY, Hart RA. Proximal junctional kyphosis and failure\u2014diagnosis, prevention, and treatment. Curr Rev Musculoskelet Med. 2016;9(3):299\u2013308."},{"issue":"17","key":"b13","series-title":"Spine (Phila Pa 1976)","first-page":"1479","article-title":"Incidence, risk factors, and natural course of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Minimum 5 years of follow-up","volume":"37","author":"Yagi M","year":"2012","unstructured":"Yagi M, King AB, Boachie-Adjei O. Incidence, risk factors, and natural course of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Minimum 5 years of follow-up. Spine (Phila Pa 1976). 2012;37(17):1479\u20131489."},{"issue":"2","key":"b14","series-title":"J Korean Neurosurg Soc","first-page":"174","article-title":"Risk factors of proximal junctional kyphosis after multilevel fusion surgery: more than 2 years follow-up data","volume":"60","author":"Kim DK","year":"2017","unstructured":"Kim DK, Kim JY, Kim DY, Rhim SC, Yoon SH. Risk factors of proximal junctional kyphosis after multilevel fusion surgery: more than 2 years follow-up data. J Korean Neurosurg Soc. 2017;60(2):174\u2013180."},{"issue":"11","key":"b15","series-title":"Spine (Phila Pa 1976)","first-page":"896","article-title":"Proximal junctional kyphosis results in inferior SRS pain subscores in adult deformity patients","volume":"38","author":"Kim HJ","year":"2013","unstructured":"Kim HJ, Bridwell KH, Lenke LG,  Proximal junctional kyphosis results in inferior SRS pain subscores in adult deformity patients. Spine (Phila Pa 1976). 2013;38(11):896\u2013901."},{"issue":"2","key":"b16","series-title":"Spine Deform","first-page":"132","article-title":"Preliminary results of the effect of prophylactic vertebroplasty on the incidence of proximal junctional complications after posterior spinal fusion to the low thoracic spine","volume":"1","author":"Martin CT","year":"2013","unstructured":"Martin CT, Skolasky RL, Mohamed AS, Kebaish KM. Preliminary results of the effect of prophylactic vertebroplasty on the incidence of proximal junctional complications after posterior spinal fusion to the low thoracic spine. Spine Deform. 2013;1(2):132\u2013138."},{"issue":"2 suppl","key":"b17","series-title":"Global Spine J","first-page":"40S","article-title":"Pre-operative planning in complex deformities and use of patient-specific UNiDTM instrumentation","volume":"12","author":"Ou-Yang D","year":"2022","unstructured":"Ou-Yang D, Burger EL, Kleck CJ. Pre-operative planning in complex deformities and use of patient-specific UNiDTM instrumentation. Global Spine J. 2022;12(2 suppl):40S\u201344S."},{"issue":"3","key":"b18","series-title":"Spine Deform","first-page":"577","article-title":"Patient-specific rods in adult spinal deformity: a systematic review","volume":"12","author":"Picton B","year":"2024","unstructured":"Picton B, Stone LE, Liang J,  Patient-specific rods in adult spinal deformity: a systematic review. Spine Deform. 2024;12(3):577\u2013585."},{"issue":"2","key":"b19","series-title":"Eur Spine J","first-page":"553","article-title":"Adult spinal deformity correction surgery using age-adjusted alignment thresholds: clinical outcomes and mechanical complication rates. A systematic review of the literature","volume":"33","author":"Quarto E","year":"2024","unstructured":"Quarto E, Zanirato A, Vitali F,  Adult spinal deformity correction surgery using age-adjusted alignment thresholds: clinical outcomes and mechanical complication rates. A systematic review of the literature. Eur Spine J. 2024;33(2):553\u2013562."},{"issue":"14","key":"b20","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. Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis. Spine (Phila Pa 1976). 2005;30(14):1643\u20131649."},{"issue":"1","key":"b21","series-title":"J Neurosurg Spine","first-page":"99","article-title":"Use of global sagittal flexibility to predict proximal junctional kyphosis after spinal deformity surgery","volume":"40","author":"Eaton RG","year":"2023","unstructured":"Eaton RG, Wang JL, Munjal V,  Use of global sagittal flexibility to predict proximal junctional kyphosis after spinal deformity surgery. J Neurosurg Spine. 2023;40(1):99\u2013106."},{"issue":"18","key":"b22","series-title":"Spine (Phila Pa 1976)","first-page":"2024","article-title":"The impact of positive sagittal balance in adult spinal deformity","volume":"30","author":"Glassman SD","year":"2005","unstructured":"Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976). 2005;30(18):2024\u20132029."},{"issue":"6","key":"b23","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":"12","key":"b24","series-title":"Spine (Phila Pa 1976)","first-page":"1077","article-title":"Scoliosis Research Society\u2014Schwab adult spinal deformity classification: a validation study","volume":"37","author":"Schwab F","year":"2012","unstructured":"Schwab F, Ungar B, Blondel B,  Scoliosis Research Society\u2014Schwab adult spinal deformity classification: a validation study. Spine (Phila Pa 1976). 2012;37(12):1077\u20131082."},{"issue":"1","key":"b25","series-title":"Eur Spine J","first-page":"47","article-title":"Sagittal alignment in lumbosacral fusion: relations between radiological parameters and pain","volume":"9","author":"Lazennec JY","year":"2000","unstructured":"Lazennec JY, Ramar\u00e9 S, Arafati N,  Sagittal alignment in lumbosacral fusion: relations between radiological parameters and pain. Eur Spine J. 2000;9(1):47\u201355."},{"issue":"25","key":"b26","series-title":"Spine (Phila Pa 1976)","first-page":"2224","article-title":"Adult spinal deformity\u2014postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery","volume":"35","author":"Schwab F","year":"2010","unstructured":"Schwab F, Patel A, Ungar B, Farcy JP, Lafage V. Adult spinal deformity\u2014postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery. Spine (Phila Pa 1976). 2010;35(25):2224\u20132231."},{"issue":"2","key":"b27","series-title":"Neurosurg Clin N Am","first-page":"157","article-title":"Sagittal spinal pelvic alignment","volume":"24","author":"Klineberg E","year":"2013","unstructured":"Klineberg E, Schwab F, Smith JS, Gupta MC, Lafage V, Bess S. Sagittal spinal pelvic alignment. Neurosurg Clin N Am. 2013;24(2):157\u2013162."},{"issue":"4","key":"b28","series-title":"Spine Surg Relat Res","first-page":"337","article-title":"Cone of economy with the chain of balance\u2014historical perspective and proof of concept","volume":"6","author":"Hasegawa K","year":"2022","unstructured":"Hasegawa K, Dubousset JF. Cone of economy with the chain of balance\u2014historical perspective and proof of concept. Spine Surg Relat Res. 2022;6(4):337\u2013349."},{"issue":"17","key":"b29","series-title":"Spine (Phila Pa 1976)","first-page":"E599","article-title":"Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity","volume":"34","author":"Lafage V","year":"2009","unstructured":"Lafage V, Schwab F, Patel A, Hawkinson N, Farcy JP. Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity. Spine (Phila Pa 1976). 2009;34(17):E599\u2013E606."},{"issue":"15","key":"b30","series-title":"Spine (Phila Pa 1976)","first-page":"1203","article-title":"T1 pelvic angle (TPA) effectively evaluates sagittal deformity and assesses radiographical surgical outcomes longitudinally","volume":"39","author":"Ryan DJ","year":"2014","unstructured":"Ryan DJ, Protopsaltis TS, Ames CP,  T1 pelvic angle (TPA) effectively evaluates sagittal deformity and assesses radiographical surgical outcomes longitudinally. Spine (Phila Pa 1976). 2014;39(15):1203\u20131210."},{"issue":"1","key":"b31","series-title":"Spine (Phila Pa 1976)","first-page":"62","article-title":"Defining spino-pelvic alignment thresholds: should operative goals in adult spinal deformity surgery account for age?","volume":"41","author":"Lafage R","year":"2016","unstructured":"Lafage R, Schwab F, Challier V,  Defining spino-pelvic alignment thresholds: should operative goals in adult spinal deformity surgery account for age? Spine (Phila Pa 1976). 2016;41(1):62\u201368."},{"issue":"3","key":"b32","series-title":"Spine Surg Relat Res","first-page":"256","article-title":"Utility of patient-specific rod instrumentation in deformity correction: single institution experience","volume":"4","author":"Sadrameli SS","year":"2020","unstructured":"Sadrameli SS, Boghani Z, Steele WJ III, Holman PJ. Utility of patient-specific rod instrumentation in deformity correction: single institution experience. Spine Surg Relat Res. 2020;4(3):256\u2013260."},{"issue":"22 Suppl","key":"b33","series-title":"Spine (Phila Pa 1976)","first-page":"S144","article-title":"Proximal junctional kyphosis as a distinct form of adjacent segment pathology after spinal deformity surgery: a systematic review","volume":"37","author":"Kim HJ","year":"2012","unstructured":"Kim HJ, Lenke LG, Shaffrey CI, Van Alstyne EM, Skelly AC. Proximal junctional kyphosis as a distinct form of adjacent segment pathology after spinal deformity surgery: a systematic review. Spine (Phila Pa 1976). 2012;37(22 Suppl):S144\u2013S164."},{"issue":"1","key":"b34","series-title":"Spine (Phila Pa 1976)","first-page":"E60","article-title":"Incidence, risk factors and classification of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis","volume":"36","author":"Yagi M","year":"2011","unstructured":"Yagi M, Akilah KB, Boachie-Adjei O. Incidence, risk factors and classification of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Spine (Phila Pa 1976). 2011;36(1):E60\u2013E68."},{"issue":"6","key":"b35","series-title":"Neurosurgery","first-page":"899","article-title":"Proximal junctional kyphosis in primary adult deformity surgery: evaluation of 20 degrees as a critical angle","volume":"72","author":"Bridwell KH","year":"2013","unstructured":"Bridwell KH, Lenke LG, Cho SK,  Proximal junctional kyphosis in primary adult deformity surgery: evaluation of 20 degrees as a critical angle. Neurosurgery. 2013;72(6):899\u2013906."},{"issue":"3","key":"b36","series-title":"Asian Spine J","first-page":"593","article-title":"Proximal junctional kyphosis: diagnosis, pathogenesis, and treatment","volume":"10","author":"Lee J","year":"2016","unstructured":"Lee J, Park YS. Proximal junctional kyphosis: diagnosis, pathogenesis, and treatment. Asian Spine J. 2016;10(3):593\u2013600."},{"issue":"4","key":"b37","series-title":"Spine J","first-page":"635","article-title":"Effect of overcorrection on proximal junctional kyphosis in adult spinal deformity: analysis by age-adjusted ideal sagittal alignment","volume":"22","author":"Byun CW","year":"2022","unstructured":"Byun CW, Cho JH, Lee CS, Lee DH, Hwang CJ. Effect of overcorrection on proximal junctional kyphosis in adult spinal deformity: analysis by age-adjusted ideal sagittal alignment. Spine J. 2022;22(4):635\u2013645."},{"key":"b38","series-title":"Adv Orthop","first-page":"8475910","article-title":"Comparison of effectiveness between cobalt chromium rods versus titanium rods for treatment of patients with spinal deformity: a systematic review and meta-analysis","volume":"2020","author":"Shega FD","year":"2020","unstructured":"Shega FD, Zhang H, Manini DR, Tang M, Liu S. Comparison of effectiveness between cobalt chromium rods versus titanium rods for treatment of patients with spinal deformity: a systematic review and meta-analysis. Adv Orthop. 2020;2020:8475910."},{"issue":"3","key":"b39","series-title":"Spine Deform","first-page":"635","article-title":"State of the art: proximal junctional kyphosis\u2014diagnosis, management and prevention","volume":"9","author":"Sardar ZM","year":"2021","unstructured":"Sardar ZM, Kim Y, Lafage V,  State of the art: proximal junctional kyphosis\u2014diagnosis, management and prevention. Spine Deform. 2021;9(3):635\u2013644."},{"issue":"9","key":"b40","series-title":"Spine (Phila Pa 1976)","first-page":"642","article-title":"Recruitment of compensatory mechanisms in sagittal spinal malalignment is age and regional deformity dependent: a full-standing axis analysis of key radiographical parameters","volume":"40","author":"Diebo BG","year":"2015","unstructured":"Diebo BG, Ferrero E, Lafage R,  Recruitment of compensatory mechanisms in sagittal spinal malalignment is age and regional deformity dependent: a full-standing axis analysis of key radiographical parameters. Spine (Phila Pa 1976). 2015;40(9):642\u2013649."},{"issue":"2","key":"b41","series-title":"Spine Surg Relat Res","first-page":"120","article-title":"Proximal junctional kyphosis in modern spine surgery: why is it so common?","volume":"7","author":"Dubousset J","year":"2023","unstructured":"Dubousset J, Diebo BG. Proximal junctional kyphosis in modern spine surgery: why is it so common?. Spine Surg Relat Res. 2023;7(2):120\u2013128."},{"issue":"15","key":"b42","series-title":"Spine (Phila Pa 1976)","first-page":"1668","article-title":"Notch sensitivity of titanium alloy, commercially pure titanium, and stainless steel spinal implants","volume":"26","author":"Dick JC","year":"2001","unstructured":"Dick JC, Bourgeault CA. Notch sensitivity of titanium alloy, commercially pure titanium, and stainless steel spinal implants. Spine (Phila Pa 1976). 2001;26(15):1668\u20131672."},{"issue":"4","key":"b43","series-title":"Spine Deform","first-page":"569","article-title":"Effects of pre-contoured and in situ contoured rods on the mechanical strength and durability of posterior cervical instrumentation: a finite-element analysis and scanning electron microscopy investigation","volume":"8","author":"Kim KD","year":"2020","unstructured":"Kim KD, Panchal R, Moldavsky M, Wang W, Bucklen BS. Effects of pre-contoured and in situ contoured rods on the mechanical strength and durability of posterior cervical instrumentation: a finite-element analysis and scanning electron microscopy investigation. Spine Deform. 2020;8(4):569\u2013576."},{"key":"b44","series-title":"Clin Biomech (Bristol)","first-page":"115","article-title":"Biomechanical musculoskeletal models of the cervical spine: a systematic literature review","volume":"71","author":"Alizadeh M","year":"2020","unstructured":"Alizadeh M, Knapik GG, Mageswaran P, Mendel E, Bourekas E, Marras WS. Biomechanical musculoskeletal models of the cervical spine: a systematic literature review. Clin Biomech (Bristol). 2020;71:115\u2013124."},{"issue":"6","key":"b1","series-title":"Asian Spine J","first-page":"886","article-title":"Adult spinal deformity: current concepts and decision-making strategies for management","volume":"14","author":"Kim HJ","year":"2020","unstructured":"Kim HJ, Yang JH, Chang DG,  Adult spinal deformity: current concepts and decision-making strategies for management. Asian Spine J. 2020;14(6):886\u2013897."},{"issue":"10193","key":"b2","series-title":"Lancet","first-page":"160","article-title":"Adult spinal deformity","volume":"394","author":"Diebo BG","year":"2019","unstructured":"Diebo BG, Shah NV, Boachie-Adjei O,  Adult spinal deformity. Lancet. 2019;394(10193):160\u2013172."},{"issue":"4","key":"b3","series-title":"Spine Deform","first-page":"310","article-title":"Adult spinal deformity: epidemiology, health impact, evaluation, and management","volume":"4","author":"Ames CP","year":"2016","unstructured":"Ames CP, Scheer JK, Lafage V,  Adult spinal deformity: epidemiology, health impact, evaluation, and management. Spine Deform. 2016;4(4):310\u2013322."},{"issue":"6","key":"b4","series-title":"Spine (Phila Pa 1976)","first-page":"602","article-title":"Adult scoliosis: a health assessment analysis by SF-36","volume":"28","author":"Schwab F","year":"2003","unstructured":"Schwab F, Dubey A, Pagala M, Gamez L, Farcy JP. Adult scoliosis: a health assessment analysis by SF-36. Spine (Phila Pa 1976). 2003;28(6):602\u2013606."},{"issue":"9","key":"b5","series-title":"Spine (Phila Pa 1976)","first-page":"1082","article-title":"Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population","volume":"30","author":"Schwab F","year":"2005","unstructured":"Schwab F, Dubey A, Gamez L,  Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine (Phila Pa 1976). 2005;30(9):1082\u20131085."},{"issue":"1","key":"b6","series-title":"Eur Spine J","first-page":"3","article-title":"Impact on health related quality of life of adult spinal deformity (ASD) compared with other chronic conditions","volume":"24","author":"Pellis\u00e9 F","year":"2015","unstructured":"Pellis\u00e9 F, Vila-Casademunt A, Ferrer M,  Impact on health related quality of life of adult spinal deformity (ASD) compared with other chronic conditions. Eur Spine J. 2015;24(1):3\u201311."},{"issue":"9","key":"b7","series-title":"Spine J","first-page":"S2","article-title":"Health impact comparison of different disease states and population norms to adult spinal deformity (ASD): a call for medical attention","volume":"12","author":"Fu KMG","year":"2012","unstructured":"Fu KMG, Bess RS, Schwab FJ,  Health impact comparison of different disease states and population norms to adult spinal deformity (ASD): a call for medical attention. Spine J. 2012;12(9):S2."},{"issue":"1","key":"b8","series-title":"Neurosurgery","first-page":"86","article-title":"Improvement of back pain with operative and nonoperative treatment in adults with scoliosis","volume":"65","author":"Smith JS","year":"2009","unstructured":"Smith JS, Shaffrey CI, Berven S,  Improvement of back pain with operative and nonoperative treatment in adults with scoliosis. Neurosurgery. 2009;65(1):86\u201394."},{"issue":"6","key":"b9","series-title":"J Neurosurg Spine","first-page":"994","article-title":"Prospective multicenter assessment of risk factors for rod fracture following surgery for adult spinal deformity","volume":"21","author":"Smith JS","year":"2014","unstructured":"Smith JS, Shaffrey E, Klineberg E,  Prospective multicenter assessment of risk factors for rod fracture following surgery for adult spinal deformity. J Neurosurg Spine. 2014;21(6):994\u20131003."},{"issue":"4","key":"b10","series-title":"Neurosurgery","first-page":"862","article-title":"Assessment of symptomatic rod fracture after posterior instrumented fusion for adult spinal deformity","volume":"71","author":"Smith JS","year":"2012","unstructured":"Smith JS, Shaffrey CI, Ames CP,  Assessment of symptomatic rod fracture after posterior instrumented fusion for adult spinal deformity. Neurosurgery. 2012;71(4):862\u2013867."},{"key":"b11","series-title":"World Neurosurg","first-page":"905","article-title":"The fate of patients with adult spinal deformity incurring rod fracture after thoracolumbar fusion","volume":"106","author":"Hamilton DK","year":"2017","unstructured":"Hamilton DK, Buza JA, Passias P,  The fate of patients with adult spinal deformity incurring rod fracture after thoracolumbar fusion. World Neurosurg. 2017;106:905\u2013911."},{"issue":"3","key":"b12","series-title":"Curr Rev Musculoskelet Med","first-page":"299","article-title":"Proximal junctional kyphosis and failure\u2014diagnosis, prevention, and treatment","volume":"9","author":"Nguyen NLM","year":"2016","unstructured":"Nguyen NLM, Kong CY, Hart RA. Proximal junctional kyphosis and failure\u2014diagnosis, prevention, and treatment. Curr Rev Musculoskelet Med. 2016;9(3):299\u2013308."},{"issue":"17","key":"b13","series-title":"Spine (Phila Pa 1976)","first-page":"1479","article-title":"Incidence, risk factors, and natural course of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Minimum 5 years of follow-up","volume":"37","author":"Yagi M","year":"2012","unstructured":"Yagi M, King AB, Boachie-Adjei O. Incidence, risk factors, and natural course of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Minimum 5 years of follow-up. Spine (Phila Pa 1976). 2012;37(17):1479\u20131489."},{"issue":"2","key":"b14","series-title":"J Korean Neurosurg Soc","first-page":"174","article-title":"Risk factors of proximal junctional kyphosis after multilevel fusion surgery: more than 2 years follow-up data","volume":"60","author":"Kim DK","year":"2017","unstructured":"Kim DK, Kim JY, Kim DY, Rhim SC, Yoon SH. Risk factors of proximal junctional kyphosis after multilevel fusion surgery: more than 2 years follow-up data. J Korean Neurosurg Soc. 2017;60(2):174\u2013180."},{"issue":"11","key":"b15","series-title":"Spine (Phila Pa 1976)","first-page":"896","article-title":"Proximal junctional kyphosis results in inferior SRS pain subscores in adult deformity patients","volume":"38","author":"Kim HJ","year":"2013","unstructured":"Kim HJ, Bridwell KH, Lenke LG,  Proximal junctional kyphosis results in inferior SRS pain subscores in adult deformity patients. Spine (Phila Pa 1976). 2013;38(11):896\u2013901."},{"issue":"2","key":"b16","series-title":"Spine Deform","first-page":"132","article-title":"Preliminary results of the effect of prophylactic vertebroplasty on the incidence of proximal junctional complications after posterior spinal fusion to the low thoracic spine","volume":"1","author":"Martin CT","year":"2013","unstructured":"Martin CT, Skolasky RL, Mohamed AS, Kebaish KM. Preliminary results of the effect of prophylactic vertebroplasty on the incidence of proximal junctional complications after posterior spinal fusion to the low thoracic spine. Spine Deform. 2013;1(2):132\u2013138."},{"issue":"2 suppl","key":"b17","series-title":"Global Spine J","first-page":"40S","article-title":"Pre-operative planning in complex deformities and use of patient-specific UNiDTM instrumentation","volume":"12","author":"Ou-Yang D","year":"2022","unstructured":"Ou-Yang D, Burger EL, Kleck CJ. Pre-operative planning in complex deformities and use of patient-specific UNiDTM instrumentation. Global Spine J. 2022;12(2 suppl):40S\u201344S."},{"issue":"3","key":"b18","series-title":"Spine Deform","first-page":"577","article-title":"Patient-specific rods in adult spinal deformity: a systematic review","volume":"12","author":"Picton B","year":"2024","unstructured":"Picton B, Stone LE, Liang J,  Patient-specific rods in adult spinal deformity: a systematic review. Spine Deform. 2024;12(3):577\u2013585."},{"issue":"2","key":"b19","series-title":"Eur Spine J","first-page":"553","article-title":"Adult spinal deformity correction surgery using age-adjusted alignment thresholds: clinical outcomes and mechanical complication rates. A systematic review of the literature","volume":"33","author":"Quarto E","year":"2024","unstructured":"Quarto E, Zanirato A, Vitali F,  Adult spinal deformity correction surgery using age-adjusted alignment thresholds: clinical outcomes and mechanical complication rates. A systematic review of the literature. Eur Spine J. 2024;33(2):553\u2013562."},{"issue":"14","key":"b20","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. Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis. Spine (Phila Pa 1976). 2005;30(14):1643\u20131649."},{"issue":"1","key":"b21","series-title":"J Neurosurg Spine","first-page":"99","article-title":"Use of global sagittal flexibility to predict proximal junctional kyphosis after spinal deformity surgery","volume":"40","author":"Eaton RG","year":"2023","unstructured":"Eaton RG, Wang JL, Munjal V,  Use of global sagittal flexibility to predict proximal junctional kyphosis after spinal deformity surgery. J Neurosurg Spine. 2023;40(1):99\u2013106."},{"issue":"18","key":"b22","series-title":"Spine (Phila Pa 1976)","first-page":"2024","article-title":"The impact of positive sagittal balance in adult spinal deformity","volume":"30","author":"Glassman SD","year":"2005","unstructured":"Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976). 2005;30(18):2024\u20132029."},{"issue":"6","key":"b23","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":"12","key":"b24","series-title":"Spine (Phila Pa 1976)","first-page":"1077","article-title":"Scoliosis Research Society\u2014Schwab adult spinal deformity classification: a validation study","volume":"37","author":"Schwab F","year":"2012","unstructured":"Schwab F, Ungar B, Blondel B,  Scoliosis Research Society\u2014Schwab adult spinal deformity classification: a validation study. Spine (Phila Pa 1976). 2012;37(12):1077\u20131082."},{"issue":"1","key":"b25","series-title":"Eur Spine J","first-page":"47","article-title":"Sagittal alignment in lumbosacral fusion: relations between radiological parameters and pain","volume":"9","author":"Lazennec JY","year":"2000","unstructured":"Lazennec JY, Ramar\u00e9 S, Arafati N,  Sagittal alignment in lumbosacral fusion: relations between radiological parameters and pain. Eur Spine J. 2000;9(1):47\u201355."},{"issue":"25","key":"b26","series-title":"Spine (Phila Pa 1976)","first-page":"2224","article-title":"Adult spinal deformity\u2014postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery","volume":"35","author":"Schwab F","year":"2010","unstructured":"Schwab F, Patel A, Ungar B, Farcy JP, Lafage V. Adult spinal deformity\u2014postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery. Spine (Phila Pa 1976). 2010;35(25):2224\u20132231."},{"issue":"2","key":"b27","series-title":"Neurosurg Clin N Am","first-page":"157","article-title":"Sagittal spinal pelvic alignment","volume":"24","author":"Klineberg E","year":"2013","unstructured":"Klineberg E, Schwab F, Smith JS, Gupta MC, Lafage V, Bess S. Sagittal spinal pelvic alignment. Neurosurg Clin N Am. 2013;24(2):157\u2013162."},{"issue":"4","key":"b28","series-title":"Spine Surg Relat Res","first-page":"337","article-title":"Cone of economy with the chain of balance\u2014historical perspective and proof of concept","volume":"6","author":"Hasegawa K","year":"2022","unstructured":"Hasegawa K, Dubousset JF. Cone of economy with the chain of balance\u2014historical perspective and proof of concept. Spine Surg Relat Res. 2022;6(4):337\u2013349."},{"issue":"17","key":"b29","series-title":"Spine (Phila Pa 1976)","first-page":"E599","article-title":"Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity","volume":"34","author":"Lafage V","year":"2009","unstructured":"Lafage V, Schwab F, Patel A, Hawkinson N, Farcy JP. Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity. Spine (Phila Pa 1976). 2009;34(17):E599\u2013E606."},{"issue":"15","key":"b30","series-title":"Spine (Phila Pa 1976)","first-page":"1203","article-title":"T1 pelvic angle (TPA) effectively evaluates sagittal deformity and assesses radiographical surgical outcomes longitudinally","volume":"39","author":"Ryan DJ","year":"2014","unstructured":"Ryan DJ, Protopsaltis TS, Ames CP,  T1 pelvic angle (TPA) effectively evaluates sagittal deformity and assesses radiographical surgical outcomes longitudinally. Spine (Phila Pa 1976). 2014;39(15):1203\u20131210."},{"issue":"1","key":"b31","series-title":"Spine (Phila Pa 1976)","first-page":"62","article-title":"Defining spino-pelvic alignment thresholds: should operative goals in adult spinal deformity surgery account for age?","volume":"41","author":"Lafage R","year":"2016","unstructured":"Lafage R, Schwab F, Challier V,  Defining spino-pelvic alignment thresholds: should operative goals in adult spinal deformity surgery account for age? Spine (Phila Pa 1976). 2016;41(1):62\u201368."},{"issue":"3","key":"b32","series-title":"Spine Surg Relat Res","first-page":"256","article-title":"Utility of patient-specific rod instrumentation in deformity correction: single institution experience","volume":"4","author":"Sadrameli SS","year":"2020","unstructured":"Sadrameli SS, Boghani Z, Steele WJ III, Holman PJ. Utility of patient-specific rod instrumentation in deformity correction: single institution experience. Spine Surg Relat Res. 2020;4(3):256\u2013260."},{"issue":"22 Suppl","key":"b33","series-title":"Spine (Phila Pa 1976)","first-page":"S144","article-title":"Proximal junctional kyphosis as a distinct form of adjacent segment pathology after spinal deformity surgery: a systematic review","volume":"37","author":"Kim HJ","year":"2012","unstructured":"Kim HJ, Lenke LG, Shaffrey CI, Van Alstyne EM, Skelly AC. Proximal junctional kyphosis as a distinct form of adjacent segment pathology after spinal deformity surgery: a systematic review. Spine (Phila Pa 1976). 2012;37(22 Suppl):S144\u2013S164."},{"issue":"1","key":"b34","series-title":"Spine (Phila Pa 1976)","first-page":"E60","article-title":"Incidence, risk factors and classification of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis","volume":"36","author":"Yagi M","year":"2011","unstructured":"Yagi M, Akilah KB, Boachie-Adjei O. Incidence, risk factors and classification of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Spine (Phila Pa 1976). 2011;36(1):E60\u2013E68."},{"issue":"6","key":"b35","series-title":"Neurosurgery","first-page":"899","article-title":"Proximal junctional kyphosis in primary adult deformity surgery: evaluation of 20 degrees as a critical angle","volume":"72","author":"Bridwell KH","year":"2013","unstructured":"Bridwell KH, Lenke LG, Cho SK,  Proximal junctional kyphosis in primary adult deformity surgery: evaluation of 20 degrees as a critical angle. Neurosurgery. 2013;72(6):899\u2013906."},{"issue":"3","key":"b36","series-title":"Asian Spine J","first-page":"593","article-title":"Proximal junctional kyphosis: diagnosis, pathogenesis, and treatment","volume":"10","author":"Lee J","year":"2016","unstructured":"Lee J, Park YS. Proximal junctional kyphosis: diagnosis, pathogenesis, and treatment. Asian Spine J. 2016;10(3):593\u2013600."},{"issue":"4","key":"b37","series-title":"Spine J","first-page":"635","article-title":"Effect of overcorrection on proximal junctional kyphosis in adult spinal deformity: analysis by age-adjusted ideal sagittal alignment","volume":"22","author":"Byun CW","year":"2022","unstructured":"Byun CW, Cho JH, Lee CS, Lee DH, Hwang CJ. Effect of overcorrection on proximal junctional kyphosis in adult spinal deformity: analysis by age-adjusted ideal sagittal alignment. Spine J. 2022;22(4):635\u2013645."},{"key":"b38","series-title":"Adv Orthop","first-page":"8475910","article-title":"Comparison of effectiveness between cobalt chromium rods versus titanium rods for treatment of patients with spinal deformity: a systematic review and meta-analysis","volume":"2020","author":"Shega FD","year":"2020","unstructured":"Shega FD, Zhang H, Manini DR, Tang M, Liu S. Comparison of effectiveness between cobalt chromium rods versus titanium rods for treatment of patients with spinal deformity: a systematic review and meta-analysis. Adv Orthop. 2020;2020:8475910."},{"issue":"3","key":"b39","series-title":"Spine Deform","first-page":"635","article-title":"State of the art: proximal junctional kyphosis\u2014diagnosis, management and prevention","volume":"9","author":"Sardar ZM","year":"2021","unstructured":"Sardar ZM, Kim Y, Lafage V,  State of the art: proximal junctional kyphosis\u2014diagnosis, management and prevention. Spine Deform. 2021;9(3):635\u2013644."},{"issue":"9","key":"b40","series-title":"Spine (Phila Pa 1976)","first-page":"642","article-title":"Recruitment of compensatory mechanisms in sagittal spinal malalignment is age and regional deformity dependent: a full-standing axis analysis of key radiographical parameters","volume":"40","author":"Diebo BG","year":"2015","unstructured":"Diebo BG, Ferrero E, Lafage R,  Recruitment of compensatory mechanisms in sagittal spinal malalignment is age and regional deformity dependent: a full-standing axis analysis of key radiographical parameters. Spine (Phila Pa 1976). 2015;40(9):642\u2013649."},{"issue":"2","key":"b41","series-title":"Spine Surg Relat Res","first-page":"120","article-title":"Proximal junctional kyphosis in modern spine surgery: why is it so common?","volume":"7","author":"Dubousset J","year":"2023","unstructured":"Dubousset J, Diebo BG. Proximal junctional kyphosis in modern spine surgery: why is it so common?. Spine Surg Relat Res. 2023;7(2):120\u2013128."},{"issue":"15","key":"b42","series-title":"Spine (Phila Pa 1976)","first-page":"1668","article-title":"Notch sensitivity of titanium alloy, commercially pure titanium, and stainless steel spinal implants","volume":"26","author":"Dick JC","year":"2001","unstructured":"Dick JC, Bourgeault CA. Notch sensitivity of titanium alloy, commercially pure titanium, and stainless steel spinal implants. Spine (Phila Pa 1976). 2001;26(15):1668\u20131672."},{"issue":"4","key":"b43","series-title":"Spine Deform","first-page":"569","article-title":"Effects of pre-contoured and in situ contoured rods on the mechanical strength and durability of posterior cervical instrumentation: a finite-element analysis and scanning electron microscopy investigation","volume":"8","author":"Kim KD","year":"2020","unstructured":"Kim KD, Panchal R, Moldavsky M, Wang W, Bucklen BS. Effects of pre-contoured and in situ contoured rods on the mechanical strength and durability of posterior cervical instrumentation: a finite-element analysis and scanning electron microscopy investigation. Spine Deform. 2020;8(4):569\u2013576."},{"key":"b44","series-title":"Clin Biomech (Bristol)","first-page":"115","article-title":"Biomechanical musculoskeletal models of the cervical spine: a systematic literature review","volume":"71","author":"Alizadeh M","year":"2020","unstructured":"Alizadeh M, Knapik GG, Mageswaran P, Mendel E, Bourekas E, Marras WS. Biomechanical musculoskeletal models of the cervical spine: a systematic literature review. Clin Biomech (Bristol). 2020;71:115\u2013124."}],"container-title":["Neurosurgical Focus"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/neurosurg-focus\/58\/6\/article-pE11.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/neurosurg-focus\/58\/6\/article-pE11.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/neurosurg-focus\/58\/6\/article-pE11.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,6]],"date-time":"2026-06-06T08:25:13Z","timestamp":1780734313000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/neurosurg-focus\/58\/6\/article-pE11.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,1]]},"references-count":88,"journal-issue":{"issue":"6"},"URL":"https:\/\/doi.org\/10.3171\/2025.3.focus259","relation":{},"ISSN":["1092-0684"],"issn-type":[{"value":"1092-0684","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6,1]]}}}