title: Degenerative Spinal Deformity.
abstract: Degenerative spinal deformity afflicts a significant portion of the elderly and is increasing in prevalence. Recent evidence has revealed sagittal plane malalignment to be a key driver of pain and disability in this population and has led to a significant shift toward a more evidence-based management paradigm. In this narrative review, we review the recent literature on the epidemiology, evaluation, management, and outcomes of degenerative adult spinal deformity (ASD). ASD is increasing in prevalence in North America due to an aging population and demographic shifts. It results from cumulative degenerative changes focused in the intervertebral discs and facet joints that occur asymmetrically to produce deformity. Deformity correction focuses on restoration of global alignment, especially in the sagittal plane, and decompression of the neural elements. General realignment goals have been established, including sagittal vertical axis <50 mm, pelvic tilt <22°, and lumbopelvic mismatch <±9°; however, these should be tailored to the patient. Operative management, in carefully selected patients, yields satisfactory outcomes that appear to be superior to nonoperative strategies. ASD is characterized by malalignment in the sagittal and/or coronal plane and, in adults, presents with pain and disability. Nonoperative management is recommended for patients with mild, nonprogressive symptoms; however, evidence of its efficacy is limited. Surgery aims to restore global spinal alignment, decompress neural elements, and achieve fusion with minimal complications. The surgical approach should balance the desired correction with the increased risk of more aggressive maneuvers. In well-selected patients, surgery yields excellent outcomes.
authors.affiliation: *Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; ‡Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri; §Department of Orthopedics, University of Utah, Salt Lake City, Utah; ¶Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania; ‖Division of Neurosurgery and Spinal Program, University of Toronto, Toronto, Ontario, Canada; #Department of Neurosurgery, University of California San Francisco, San Francisco, California.
authors.forename: Tamir
authors.initials: T
authors.lastname: Ailon
authors.forename: Justin S
authors.initials: JS
authors.lastname: Smith
authors.forename: Christopher I
authors.initials: CI
authors.lastname: Shaffrey
authors.forename: Lawrence G
authors.initials: LG
authors.lastname: Lenke
authors.forename: Darrel
authors.initials: D
authors.lastname: Brodke
authors.forename: James S
authors.initials: JS
authors.lastname: Harrop
authors.forename: Michael
authors.initials: M
authors.lastname: Fehlings
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Ames
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019299:Decompression, Surgical; D006801:Humans; D055959:Intervertebral Disc Degeneration / Q000150:complications*; D007738:Kyphosis / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D008141:Lordosis / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D012600:Scoliosis / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D012720:Severity of Illness Index; D013117:Spinal Cord Compression / Q000209:etiology / Q000601:surgery; D013122:Spinal Diseases; D013123:Spinal Fusion; D021801:Zygapophyseal Joint