{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,12]],"date-time":"2026-08-12T12:27:46Z","timestamp":1786537666930,"version":"build-2736575974"},"reference-count":149,"publisher":"MDPI AG","issue":"16","license":[{"start":{"date-parts":[[2026,8,12]],"date-time":"2026-08-12T00:00:00Z","timestamp":1786492800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Background: Adolescent idiopathic scoliosis (AIS) affects approximately 0.5\u20135.2% of adolescents. Only a minority of curves progress, and surgery is generally reserved for curves exceeding 45\u201350\u00b0. Selection of the lowest instrumented vertebra (LIV) remains contested and directly influences postoperative coronal balance, distal adding-on (DA) and revision risk. Aim: This narrative review synthesizes the biomechanical principles governing LIV selection, compares traditional anatomical landmarks with contemporary prediction formulas and machine learning (ML) tools, and defines what these tools can and cannot currently deliver at the bedside. Methods: A structured but deliberately non-systematic search of PubMed\/MEDLINE, EMBASE and the Cochrane Library (January 2000\u2013December 2024) was supplemented by purposive inclusion of seminal pre-2000 work. No PRISMA-compliant screening, risk-of-bias appraisal or quantitative synthesis was undertaken, and the article is therefore reported as a narrative review. Results: Traditional landmarks\u2014end, neutral, stable, last touched (LTV) and last substantially touched vertebra (LSTV)\u2014are compared; fusion at or distal to the LTV\/LSTV lowers DA incidence, yet 8\u201328% of patients still develop DA. Prediction formulas estimate the residual lumbar curve to within approximately 6\u00b0, but each was derived within a single surgical team and none nominates a vertebral level. A composite index combining (LIV\u2212 Neutral vertebra) and (LIV\u2212 Stable vertebra) reported sensitivity 100% and specificity 92\u201394% in its derivation cohort, without external validation. Hypercorrection of the main thoracic curve (&gt;53%) combined with postoperative LIV tilt &lt; 10\u00b0 is associated with DA. Machine learning models predict three-dimensional alignment within 5\u20137\u00b0, yet every published model predicts an outcome; none has shown that acting on a model-derived recommendation prevents DA. Conclusions: LIV selection is best framed as a multidimensional judgment integrating coronal balance, vertebral body rotation, sagittal alignment, skeletal maturity, lumbopelvic morphology and non-radiographic factors such as paraspinal muscle quality, bracing and rehabilitation. Prediction models and artificial intelligence remain hypothesis-generating: external validation and prospective outcome trials are prerequisites before they can be considered practice-changing.<\/jats:p>","DOI":"10.3390\/jcm15166241","type":"journal-article","created":{"date-parts":[[2026,8,12]],"date-time":"2026-08-12T11:02:11Z","timestamp":1786532531000},"page":"6241","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Principles Underlying Surgical Decision-Making in Lowest-Instrumented Vertebra Level Selection of Adolescent Idiopathic Scoliosis: From Traditional Landmarks to Emerging Predictive Models\u2014A Narrative Review"],"prefix":"10.3390","volume":"15","author":[{"given":"Yu-Chun","family":"Liu","sequence":"first","affiliation":[{"name":"Department of Orthopedics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chih-Hsuan","family":"Yu","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hung-Kuan","family":"Yen","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, National Taiwan University College of Medicine, National Taiwan University Hospital, Taipei 100, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"I-Hsin","family":"Chen","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan"},{"name":"Department of Orthopedics, National Taiwan University College of Medicine, National Taiwan University Hospital, Taipei 100, Taiwan"},{"name":"Graduate Institute of Biomedical Engineering, National Taiwan University, Taipei 106, Taiwan"},{"name":"Department of Chemical Engineering and Biotechnology, Tatung University, Taipei 104, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,12]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1007\/s11832-012-0457-4","article-title":"Epidemiology of adolescent idiopathic scoliosis","volume":"7","author":"Konieczny","year":"2013","journal-title":"J. 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