{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T00:48:42Z","timestamp":1791938922617,"version":"4.3.4"},"reference-count":31,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,10,9]]},"abstract":"<jats:sec>\n                    <jats:title>OBJECTIVE<\/jats:title>\n                    <jats:p>The T4\u2013L1 pelvic angle (T4-L1PA) has been proposed as a novel alignment target associated with mechanical complications in long-segment adult spinal deformity (ASD) surgery. However, its relationship to proximal junctional failure (PJF) and its relevance in shorter thoracolumbar constructs remain unclear. The aim of this study was to evaluate whether T4-L1PA and L1 pelvic angle (L1PA) guidelines predict PJF in ASD surgery and to examine how early proximal reciprocal changes influence this relationship.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS<\/jats:title>\n                    <jats:p>A prospective ASD database was reviewed for patients who underwent fusion from the ilium to the thoracic spine with a minimum follow-up of 2 years. Postoperative PJF was defined as 1) revision surgery requiring proximal extension or 2) severe radiographic proximal junctional kyphosis (PJK) (proximal junctional angle [PJA] &gt; 28\u00b0 and \u0394PJA &gt; 22\u00b0). Patients were categorized based on adherence to L1PA (0.5 \u00d7 PI \u221219 \u00b1 2\u00b0) and T4-L1PA (from \u22123\u00b0 to 1\u00b0) guidelines, stratified by upper instrumented vertebra position (upper thoracic [UT], T2\u20134; lower thoracic, T9\u201311). Simulated postoperative alignment was used to assess the effect of the PJA on guideline adherence and failure risk.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS<\/jats:title>\n                    <jats:p>Among 661 patients (78% female, mean age 65 \u00b1 9 years, mean BMI 28.3 \u00b1 5.7), 17.9% experienced PJF at 2 years (8.3% with revision, 10.4% with severe PJK). Patients with UT UIVs had higher failure rates when L1PA was overcorrected (25.6%) versus matching (12.9%) or undercorrected (11.1%, p = 0.029). In contrast, failure rates across T4-L1PA groups were not different (p = 0.094). The lowest failure rate was identified for either L1PA undercorrected and T4 aligned or L1PA aligned but T4 ventral to L1. For short fusion, no significant differences were found across L1PA guidelines (p = 0.132), and the significant difference in T4-L1PA was not maintained after adjusting for PJA influence on early postoperative alignment (p = 0.148). Similarly, no significant differences were found across the 9 combinations after controlling for PJA influence.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS<\/jats:title>\n                    <jats:p>The T4-L1PA concept demonstrated some association with PJF alone in the setting of long fusions, although adjusting L1PA thresholds toward less correction might further improve outcomes. Unfortunately, current targets seem inappropriate for short fusions, and a different framework might be required.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/2026.4.spine251528","type":"journal-article","created":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T00:01:18Z","timestamp":1791331278000},"page":"1-10","source":"Crossref","is-referenced-by-count":0,"title":["Rethinking sagittal alignment: the value of evaluating spinal shape in conjunction with T4\u2013L1 pelvic angle measurement to prevent proximal junctional failure"],"prefix":"10.3171","author":[{"given":"Renaud","family":"Lafage","sequence":"first","affiliation":[{"name":"Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fares","family":"Ani","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York;"},{"name":"Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Themistocles","family":"Protopsaltis","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Max","family":"Kohn","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shay","family":"Bess","sequence":"additional","affiliation":[{"name":"Denver International Spine Center, Presbyterian St. Luke\u2019s\/Rocky Mountain Hospital for Children, Denver, Colorado;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alan H.","family":"Daniels","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Warren Alpert Medical School, Brown University, Providence, Rhode Island;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bassel G.","family":"Diebo","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Warren Alpert Medical School, Brown University, Providence, Rhode Island;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert K.","family":"Eastlack","sequence":"additional","affiliation":[{"name":"Division of Orthopedic Surgery, Scripps Clinic, La Jolla, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Munish C.","family":"Gupta","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Washington University in St. Louis, Missouri;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard","family":"Hostin","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Baylor Scoliosis Center, Dallas, Texas;"}],"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":"Eric O.","family":"Klineberg","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, University of Texas Health Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gregory M.","family":"Mundis","sequence":"additional","affiliation":[{"name":"Division of Orthopedic Surgery, Scripps Clinic, La Jolla, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David O.","family":"Okonkwo","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Pittsburgh Medical Center Presbyterian, Pittsburgh, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter G.","family":"Passias","sequence":"additional","affiliation":[{"name":"Division of Spine Surgery, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher P.","family":"Ames","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frank","family":"Schwab","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher I.","family":"Shaffrey","sequence":"additional","affiliation":[{"name":"Division of Spine Surgery, Department of Orthopaedic 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":"Virginie","family":"Lafage","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"_","family":"_","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"3","key":"b1","series-title":"Spine (Phila Pa 1976)","first-page":"224","article-title":"The health impact of symptomatic adult spinal deformity: comparison of deformity types to United States population norms and chronic diseases","volume":"41","author":"Bess S","year":"2016","unstructured":"Bess S, Line B, Fu KM,  The health impact of symptomatic adult spinal deformity: comparison of deformity types to United States population norms and chronic diseases. 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