Study DesignProspective multicenter cohort study.ObjectivesIntegration of robotic guidance with navigation represents a natural evolution in spine surgery technologies. Both modalities have independently demonstrated improved implant accuracy, reduced radiation exposure, and expanded minimally invasive capabilities, yet data on integrated platforms remain limited. The Prospective Robotic-Guided Registry of Spine Surgery (PRoGRSS) evaluates surgical, clinical, and patient-reported outcomes across a broad range of procedures performed with an integrated robotic-assisted navigation system.MethodsAdults undergoing navigated robotic thoracolumbar surgery between 2020 and 2024 were enrolled by six surgeons across four centers. Demographic, surgical, and robot-related metrics were collected. Patient-reported outcomes included ODI and PROMIS Global Health, Physical Function, and Pain Interference. Complications, revision surgery, inpatient resource utilization, and return-to-work metrics were analyzed.ResultsOf 657 enrolled patients, 606 completed 12-month follow-up (92%). Median age was 60 years; 49.9% were female. Of 5166 planned screws, 99.2% were placed, with 98.4% accurately positioned and 1.5% malpositioned. Robot abandonment occurred in 0.6% of cases. Robot-related intraoperative or postoperative adverse events occurred in 0.3% of cases. Twelve-month revision surgery rate was 4.8%, including 0.3% robot-related revisions. Resource utilization was low: 5.2% required transfusion, 2.1% postoperative CT, median length of stay was 3 days, and 88.4% were discharged home. Patients demonstrated significant, clinically meaningful improvement across all PRO domains.ConclusionsThis large prospective evaluation of an integrated navigation-robotic platform demonstrates high accuracy, low complication and revision rates, efficient resource use, and substantial patient-reported outcome improvement, establishing a contemporary benchmark for navigated robotic spine surgery.

OBJECTIVE:The objective of this study was to determine whether patient-specific precontoured rod (PCR) instrumentation is associated with lower rates of proximal junctional kyphosis (PJK) compared with manually contoured conventional rods (CRs) in adult spinal deformity (ASD) surgery. METHODS:The data of ASD patients (age ≥ 18 years) undergoing posterior spinal instrumentation and fusion of a minimum of 5 levels were consecutively reviewed from 2016 to 2021. A propensity score-matching algorithm was used to match patients undergoing instrumentation with PCRs (n = 80) to those treated with CRs (n = 210). The primary outcome was the rate of radiographic PJK at a minimum follow-up of 1 year. PJK was defined by two criteria: a postoperative proximal junctional sagittal angle (PJA) 1) ≥ 10° and 2) at least 10° greater than the preoperative measurement. RESULTS:Following propensity score matching, 160 patients were included in the study (80 per group). Patients demonstrated similar preoperative baseline characteristics and preoperative radiographic alignment. Preoperatively, the mean PJAs measured 9.24° ± 6.8° and 8.8° ± 7.3° for the PCR and CR groups, respectively (p = 0.751). At the most recent follow-up, the PCR and CR groups demonstrated mean PJAs of 11.6° ± 9.1° and 10.8° ± 8.3°, respectively (p = 0.545). Ten (12.5%) patients experienced PJK in the PCR group compared to 16 (20%) patients in the CR group (p = 0.199). In patients with upper instrumented vertebrae in the lower thoracic region, 5 (11.1%) patients in the PCR group experienced PJK versus 12 (26.7%) patients in the CR group (p = 0.059). Furthermore, 7 (10.9%) patients in the PCR group experienced PJK compared to 14 (21.5%) patients in the CR group after including patients with fusion to the sacrum/pelvis (p = 0.103). CONCLUSIONS:Lower rates of PJK were observed in the PCR group when compared to the CR cohort. However, this relationship was not statistically significant. Future studies with longer-term follow-up and larger sample sizes are warranted to investigate the relationship between PCR instrumentation and PJK prophylaxis. While PCR technology alone is likely not a definitive solution for preventing PJK, its strength lies in enabling rigorous preoperative planning and thoughtful deformity correction strategies. When integrated into a comprehensive approach to patient optimization, alignment, and junctional control, PCRs may serve as a useful adjunct in mitigating PJK risk.

Study DesignRetrospective, Single-center.ObjectiveTo evaluate preoperative cervical range-of-motion via cervical flexion-extension radiographs and its relation to the development of PJK/PJF following ASD correction in patients with a UIV in the upper thoracic spine.MethodsPatients with an UIV between T1-T4, preoperative cervical flexion/extension radiographs and instrumented to the pelvis, and minimum 1yr follow-up were included. Cervical measurements included range-of-motion (ROM), flexion, extension and cervical SVA (cSVA). Patients were stratified into 3 groups: No-PJK, asymptomatic PJK (A-PJK) and symptomatic PJK including PJF (S-PJK/PJF).Results151 patients were included: Mean age 59.6 ± 8.0 yrs, BMI of 25.1 ± 4.5, 88.7% (n = 134) were female. PJK status: No PJK = 111 (73.5%) patients, A-PJK = 21 (13.9%), S-PJK/PJF = 19 (12.6%). S-PJK/PJF patients, however, were more likely to be diagnosed with osteopenia/osteoporosis(S-PJK/PJF: 68.4% vs A-PJK: 23.8% vs No PJK: 52.3%, P = 0.0138). S-PJK/PJF patients had significantly less cervical flexion (No PJK: 19.5 ± 14.2 vs A-PJK: 19.9 ± 10.9 vs S-PJK/PJF: 7.7 ± 11.9, P = 0.0029) and ROM than the other groups (No PJK: 52.8 ± 17.7 vs A-PJK: 53.1 ± 14.5 vs S-PJK/PJF: 39.2 ± 17.9, P = 0.0085). On multivariable models for the development of S-PJK/PJF, reduced baseline cervical flexion and ROM were independent risk factors yielding threshold values of 22.8° and 48.2°, respectively.ConclusionMultivariable models for the development of S-PJK/PJF demonstrated that reduced baseline cervical ROM and flexion were independent risk factors yielding threshold values of 48.2° and 22.8°, respectively. All of S-PJK/PJF patients had preop flexion <22.8°. Flexion-extension radiographs provide a quick and easy option at a relatively low cost to offer additional information that may aid in surgical planning and shared decision making with the patient regarding potential outcomes.

To compare patient-reported outcomes (PROs) in adult spinal deformity (ASD) patients reoperated within six months of their index surgery to patients without readmissions/reoperations and note any similarities/dissimilarities in activity and pain outcomes. ASD patients who underwent spinal fusion at a single institution with minimum two years follow-up were included. Patients without readmissions/reoperations (No Reops) were compared to those requiring early reoperation resolved by six months post-index procedure (Early Reop) cohort. Outcomes included 2Y PROs, improvement, and MCID attainment. Question 22 from the SRS-22r, assessing likelihood of choosing the same treatment, was separately evaluated. 238 patients [211(89

BACKGROUND:Individually, robotic guidance and 3-dimensional navigation assistance have been shown to improve surgical outcomes and accuracy in spine surgery. The pairing of these technologies may further improve outcomes; however, data are needed to support this theory. In the Prospective Robotic-Guided Registry of Spine Surgery (PRoGRSS), outcomes were tracked for cases using a bone-mounted integrated robotic-assisted navigation system. This interim analysis reports on 90-day complications and revisions. METHODS:Adults undergoing navigated robotic thoracolumbar surgery from 2020 to 2022 were prospectively enrolled by 6 surgeons at 4 distinct centers. Medical, surgical, and robot-related complications and revision surgeries were collected postoperatively for up to 90 days and analyzed. RESULTS:Of 411 surgeries, 3469 screws were implanted. The mean number of levels fused was 4.4 ± 3.7. Intraoperative adverse events occurred in 4.1% of cases, and 0.5% were robot related. The frequency of patients with at least 1 postoperative surgical complication was 6.6%, none being robot related. The frequency of patients with at least 1 postoperative medical complication was 18.2%. The revision surgery rate at 90 days was 1.5%, none of which were robot related. CONCLUSION:This first-of-its-kind study of an integrated navigation and robotic spine platform demonstrates low complication and revision surgery rates for thoracolumbar fusion. This interim analysis of PRoGRSS showed 4.1% intraoperative complications, 6.6% postoperative surgical complications, and 1.5% revision surgeries. With advancements in technology and increased surgical expertise, navigated robotics continues to demonstrate consistently low rates of 90-day complications and revision surgeries, supporting its reliability. CLINICAL RELEVANCE:The interim analysis of PRoGRSS suggests that the integration of robotic guidance with 3-dimensional navigation is reproducibly effective in the surgical setting. LEVEL OF EVIDENCE: 2:

STUDY DESIGN:Single-center retrospective analysis. OBJECTIVE:To establish an empirically derived threshold to define both coronal and sagittal malalignment (CM & SM) based on preoperative patient-reported outcomes (PROs). SUMMARY OF BACKGROUND DATA:Currently, no radiographic alignment threshold defines preoperative CM in adult spinal deformity (ASD) patients based on disability. In a cohort of ASD patients undergoing corrective surgery, we sought to establish a threshold to define both CM and SM based on PRO and assess the clinical impact of CM and combined with SM. METHODS:ASD patients with ≥6 level fusions were included. CVA and SVA were measured. PROs included preoperative ODI and SRS-22r scores. CVA and SVA thresholds were derived to accurately differentiate patients with ODI >40 and SRS-pain+function <5. Patients were then separated into 4 groups: (1) neutral alignment (NA); (2) CM; (3) SM; and (4) combined coronal and sagittal malalignment (CCSM). RESULTS:Totally, 368 patients were included. Thresholds to distinguish patients with ODI ≥40 and SRS-pain/function <5 were: (1) CVA=3.96 cm (ODI) and 3.17 cm (SRS); (2) SVA=4.97 cm (ODI) and 7.52 cm (SRS). The lower numbers were chosen to define each threshold: CVA=3 cm and SVA=5 cm. Alignment breakdown was: NA=179 (48.6%), CM=66 (17.9%), SM=65 (17.7%), and CCSM=58 (15.8%). Both SM=( P =0.006) and CCSM ( P <0.001) patients had significantly worse ODI scores than NA patients, and CCSM patients were significantly worse than SM alone ( P =0.010). On the basis of preoperative total SRS-22r scores, only CCSM ( P =0.003) patients were significantly worse than the NA group. CVA significantly correlated with 4/7 (57.1%) preoperative PROs (ODI/SRS-total/function/image), while SVA correlated with 5/7 (71.4%) preoperative PROs (ODI/SRS-total/function/image/pain). A linear relationship was seen between increasing CVA and worsening ODI (β=0.92, 95% CI: 0.37-1.48, P =0.001). A significant and slightly stronger relationship was seen between increasing SVA and worsening ODI (β=1.28, 95% CI: 1.00-1.56, P <0.001). CONCLUSIONS:CM and SM thresholds that accurately distinguished ASD patients with severe pain and disability preoperatively were 3 cm for CVA and 5 cm for SVA, respectively. Preoperative CM was significantly associated with worse ODI, SRS-22r total/function/image scores. CCSM led to more disability than SM alone.

STUDY DESIGN:Single-center retrospective cohort study. OBJECTIVE:To determine if the 4-rod construct (4RC) is protective against the occurrence of rod fractures when compared with the 3-rod construct (3RC) in adult spinal deformity (ASD) patients with long fusions to the sacrum. SUMMARY OF BACKGROUND DATA:Past studies have explored the different outcomes in subjects with dual-rod versus multirod constructs. There is a lack of literature distinguishing the ramifications of 3RC versus 4RC, particularly in the prevalence of rod fractures and rod fractures requiring subsequent revision surgery as a result of pseudarthrosis. METHODS:ASD patients undergoing long instrumented fusions to the sacrum were dichotomized between the 3RC and 4RC cohorts. Outcomes of interest include the occurrence of rod fractures (RFs) and RFs requiring revision (RFR). Two-tailed independent-sample t test with Welch's correction and χ 2 /Fisher exact test were used for continuous and categorical variables, respectively. Multivariable logistic regression analysis was performed to assess whether the 4RC is protective against rod fractures when compared with the 3RC. RESULTS:One hundred forty-five patients with a minimum 2-year follow-up were included (3RC=57, 4RC=88). Four RC had a greater body mass index (BMI) ( P =0.002), longer operating room (OR) time ( P =0.002), greater estimated blood loss (EBL) ( P =0.002), total instrumented levels (TIL) ( P =0.028), and more 3-column osteotomies (3COs) performed ( P =0.028). Four RC had greater baseline coronal vertical axis (CVA) (28.2±24.9 vs. 18.5±16.9 mm, P =0.006) and sagittal vertical axis (SVA) (55.1±64.8 vs. 30.4±41.8 mm, P =0.006). Three RC had a greater rate of RF (28.1% vs. 14.8%, P =0.0506) and RFR (14.9% vs. 10.2%, P =0.486) when compared with 4RC, but these findings were not statistically significant. After controlling for BMI, the use of 3-column osteotomies, total instrumented levels, change in coronal alignment (∆CVA), change in sagittal alignment (∆SVA), use of bone morphogenetic protein, and number of interbody fusions, 3RC was associated with 4.93× greater odds of experiencing RFs ( P =0.0078). However, significance fell short when adjusting for the occurrence of RFR [OR=2.58 (0.60-11.19), P =0.2067]. CONCLUSION:ASD patients having long fusions to the sacrum with 4RC across the lumbosacral junction are shown to be at lesser risk of developing rod fractures but not revision surgery as compared with 3RC at 2-year follow-up.

To assess risk factors associated with an increased risk of intraoperative neuromonitoring (IONM) loss among spinal deformity patients with type 3 spinal cord (T3SC) shapes. This is a retrospective cohort study of adult and pediatric patients with T3SC undergoing spinal deformity surgery from a single center between 2016 and 2023. The primary outcome examined was whether there was IONM data loss. Demographic, clinical, operative, and radiographic variables were compared between patients with and without IONM data loss. A total of 79 patients with T3SC were identified: 31 (39.2

To better elucidate the C2-related complications and treatments among ASD patients with C2–ilium fusions. A single-center series of patients who underwent a posterior spinal instrumented fusion (PSIF) from C2–ilium were included. Patient demographics, medical history, diagnosis, operative procedures, and complications were analyzed. 37 C2–ilium patients were included with a mean follow-up of 2.8 years, age of 56 ± 19 years, 57

Single-center retrospective cohort study. To determine if the 4-rod construct (4RC) is protective against the occurrence of rod fractures when compared with the 3-rod construct (3RC) in adult spinal deformity (ASD) patients with long fusions to the sacrum. Past studies have explored the different outcomes in subjects with dual-rod versus multirod constructs. There is a lack of literature distinguishing the ramifications of 3RC versus 4RC, particularly in the prevalence of rod fractures and rod fractures requiring subsequent revision surgery as a result of pseudarthrosis. ASD patients undergoing long instrumented fusions to the sacrum were dichotomized between the 3RC and 4RC cohorts. Outcomes of interest include the occurrence of rod fractures (RFs) and RFs requiring revision (RFR). Two-tailed independent-sample t test with Welch's correction and χ2/Fisher exact test were used for continuous and categorical variables, respectively. Multivariable logistic regression analysis was performed to assess whether the 4RC is protective against rod fractures when compared with the 3RC. One hundred forty-five patients with a minimum 2-year follow-up were included (3RC=57, 4RC=88). Four RC had a greater body mass index (BMI) (P=0.002), longer operating room (OR) time (P=0.002), greater estimated blood loss (EBL) (P=0.002), total instrumented levels (TIL) (P=0.028), and more 3-column osteotomies (3COs) performed (P=0.028). Four RC had greater baseline coronal vertical axis (CVA) (28.2±24.9 vs. 18.5±16.9 mm, P=0.006) and sagittal vertical axis (SVA) (55.1±64.8 vs. 30.4±41.8 mm, P=0.006). Three RC had a greater rate of RF (28.1% vs. 14.8%, P=0.0506) and RFR (14.9% vs. 10.2%, P=0.486) when compared with 4RC, but these findings were not statistically significant. After controlling for BMI, the use of 3-column osteotomies, total instrumented levels, change in coronal alignment (∆CVA), change in sagittal alignment (∆SVA), use of bone morphogenetic protein, and number of interbody fusions, 3RC was associated with 4.93× greater odds of experiencing RFs (P=0.0078). However, significance fell short when adjusting for the occurrence of RFR [OR=2.58 (0.60–11.19), P=0.2067]. ASD patients having long fusions to the sacrum with 4RC across the lumbosacral junction are shown to be at lesser risk of developing rod fractures but not revision surgery as compared with 3RC at 2-year follow-up.

OBJECTIVE The objective of this study was to discern whether patients who achieve a cranial sagittal vertical axis to the hip (CrSVA-H) < 2 cm at 2 years of follow-up, regardless of mismatch between pelvic incidence and lumbar lordosis (PI-LL), have a greater improvement in patient-reported outcome measures (PROMs). METHODS This was a retrospective analysis of a prospectively collected single-center database of adult spinal deformity (ASD) patients who underwent corrective surgery with a minimum follow-up of 2 years. Patient demographics, perioperative data, radiographic parameters, and PROMs were collected at baseline and follow-up. Patients were placed into four cohorts: combined aligned (CA) (CrSVA-H < 2 cm, PI-LL < 10°), globally aligned (GA) (CrSVA-H < 2 cm, PI-LL ≥ 10°), regionally aligned (RA) (CrSVA-H ≥ 2 cm, PI-LL < 10°), and completely malaligned (CM) (CrSVA-H ≥ 2 cm, PI-LL ≥ 10°) at final follow-up. RESULTS A total of 162 patients were included (71 CA, 58 GA, 11 RA, and 22 CM patients). The CA cohort was younger (mean [standard error of the mean]: 44.1 [2.2] vs 57.6 [1.8] vs 54.7 [3.1] years, p = 0.0003) and had a smaller PI-LL (1.6° [2.3°] vs 27.9° [2.4°] vs 25.0° [4.8°], p < 0.0001) than the GA and CM cohorts. The CrSVA-H differed significantly between the CA and CM cohorts (−1.5 [0.5] vs 4.1 [1.2] cm, p = 0.0012). There was no significant difference in BMI or total instrumented levels across all four cohorts (p > 0.05). The CA and GA cohorts had greater baseline PROMs when compared with the CM cohort, specifically in the SRS-22r total score (p = 0.0025 and p = 0.0244, respectively), self-image (p = 0.0032 and p = 0.0074, respectively), and satisfaction (p = 0.0313 and p = 0.0011, respectively) domains. Baseline Oswestry Disability Index (ODI) scores differed only between the CA and CM cohorts (32.2 [2.5] vs 41.1 [2.4], p = 0.0312). The CA and GA cohorts possessed greater PROMs by the final follow-up, including the aforementioned PROMs (p = 0.0016) and ODI scores (p = 0.0044) when compared with the CM cohort. The mixed-effects model of PROMs demonstrated that the CA and GA cohorts experienced a greater increase in patient-reported outcomes when compared with the CM cohort (p < 0.05). CONCLUSIONS ASD patients with a CrSVA-H < 2 cm by the final follow-up improved significantly across the majority of PROMs regardless of regional alignment when compared with patients who were both globally and regionally malaligned. These results further emphasize that the position of the head relative to the hips is a vital measure for the long-term improvement of PROMs following ASD surgery.

The artificial intelligence (AI) revolution is underway. AI has become omnipresent in medicine, and its broad capabilities have permitted significant developments in many subspecialties including spine surgery. With AI, spine surgeons have been able to perform advanced computational analytics on vast amounts of data, allowing for solutions in each step of patient care from preoperative evaluation and planning, intraoperative execution, and postoperative evaluation. The tremendous potential of AI in medicine is clear and exciting. However, as the utility of AI in clinical practice expands, the medicolegal implications of this technology are poorly understood. In this chapter, we explore the existing technology, ethical considerations, legal challenges, and risk management strategies as it relates to AI in the field of spine surgery.

Robot-assisted spine surgery has gained notable popularity among surgeons because of recent advancements in technology. These innovations provide several key benefits, including high screw accuracy rates, reduced radiation exposure, customized preoperative and intraoperative planning options, and improved ergonomics for surgeons. Despite the promising outcomes reported in literature, potential technical challenges remain across various robotic platforms. It is crucial for surgeons to remember that robotic platforms are shared-control systems, requiring the surgeon to maintain primary control throughout the procedure. To ensure patient safety, surgeons should be well versed in common technical pitfalls and strategies to mitigate these limitations.

Background: Large data analysis of anterior cruciate ligament reconstruction (ACLR) short-term complications on age will help surgeons stratify and counsel at-risk patients. The purpose of this study is to assess if older patients are at greater risk for short-term complications after ACLR.Methods: This retrospective cohort study included patients who underwent elective ACLR with or without concomitant meniscal procedures in the National Surgical Quality Improvement Program from 2005 to 2017. Patients were divided into age groups 16-30, 31-45, and > 45. Modified fragility index-5 (mFI-5), demographics and short-term outcomes were examined with bivariate and multivariate analysis to determine if age was a risk factor for complications.Results: A total of 23,581 patients (35.4% female) were included in this analysis. Mean age was 32.1 +/- 10.8 years. Older patients had higher mFI-5 scores (p < 0.001), shorter operative times (p < 0.001), lower use of only general anesthesia (p < 0.001). The oldest patients had similar rates of complications as the two younger groups. Older age was an independent risk factor for VTE, but decreased risk of prolonged operations. A mFI-5 > 0 increased risk factors for readmission (Odds ratio 2.2, P = 0.006). Infection was the most common cause 30-day readmissions (40/135, 29.6%).Conclusion: In the early postoperative period, older age is an independent risk factor for VTE and younger age is a significant factor for prolonged surgeries. Having an mFI-5 > 0 increased risk factors for readmission.

Early onset scoliosis (EOS) patient diversity makes outcome prediction challenging. Machine learning offers an innovative approach to analyze patient data and predict results, including LOS in pediatric spinal deformity surgery. Children under 10 with EOS were chosen from the American College of Surgeon’s NSQIP database. Extended LOS, defined as over 5 days, was predicted using feature selection and machine learning in Python. The best model, determined by the area under the curve (AUC), was optimized and used to create a risk calculator for prolonged LOS. The study included 1587 patients, mostly young (average age: 6.94 ± 2.58 years), with 33.1

Spinal deformity surgery often requires complex surgical interventions that can have a drastic effect on both patient quality of life and functional capacity. Modern-day corrective solutions for these deformities include spinal osteotomies, pedicle screw instrumentation, and dual/multirod constructs. These solutions are efficacious and are currently considered standard practice for spinal surgeons, but they lack individualization. Patient-specific rods (PSRs) are a novel technology that attempts to offer a personalized approach to spinal deformity correction based on preoperative computerized tomography scans. Moreover, PSRs may offer several advantages to conventional rods, which include achievement of desired rod contour angles according to surgical planning alignment goals, reduced operative time, and reduced blood loss. In adolescent idiopathic scoliosis, those instrumented with PSR have observed coronal Cobb reductions up to 74%. In adult spinal deformity, PSRs have offered superior correction in radiographic parameters such as sagittal vertical axis and pelvic incidence minus lumbar lordosis. However, there still remains a paucity of research in this area, mainly in health care expenditure, cost-effectiveness, and longitudinal clinical outcomes. The purpose of this article is to survey the current body of knowledge of PSR instrumentation in both adolescent and adult spinal deformity populations. The current strength, limitations, and future directions of PSRs are highlighted throughout this article.

OBJECTIVE The objective was to discern whether the cranial sagittal vertical axis (CrSVA) can best predict the trajectory of patient-reported outcome measures (PROMs) at 2 years postoperatively. METHODS This was a retrospective cohort study of prospectively collected adult spinal deformity patient data. CrSVA relative to the sacrum, hip (CrSVA-H), knee, and ankle was measured as the horizontal distance to the vertical plumb line from the nasion-inion midpoint, with positive values indicating an anterior cranium. Standard sagittal alignment parameters were also collected. Outcome variables were PROMs as measured by Scoliosis Research Society-22r questionnaire (SRS-22r) total and subdomain scores and the Oswestry Disability Index. Pearson’s correlation coefficients and univariate regressions were performed to investigate associations between predictors and PROMs. Two conceptual multivariable linear regression models for each 2-year outcome measure were built after adjusting for the impact of preoperative SRS-22r scores. Model 1 assessed pre- and postoperative alignment only relative to C2 and C7, while model 2 assessed alignment relative to C2 and C7 as well as the cranium. RESULTS There was a total of 363 patients with 2 years of radiographic and PROM follow-up (68.0% female, mean [standard error of the mean] age 60.8 [0.78] years, BMI 27.5 [0.29], and total number of instrumented levels 12.8 [0.22]). CrSVA measures were significantly associated with the 2-year SRS-22r total and subdomain scores. In univariate regression, revision surgery, number of prior surgeries, frailty, BMI, total number of osteotomies, and lower baseline total SRS-22r score as well as postoperative sagittal alignment were significantly associated with worse 2-year SRS-22r scores. In multivariable regression, after adjusting for baseline SRS-22r scores, greater preoperative C2 to sacrum sagittal vertical axis (SVA) and C7 SVA were found to be the only independent predictors of 2-year total SRS-22r score (β = −0.011 [p = 0.0026] and β = 0.009 [p = 0.0211], respectively) when alignment was considered only relative to C2. However, in the subsequent model, CrSVA-H replaced C7 SVA as the independent factor driving postoperative SRS-22r total scores (β = −0.006, p < 0.0001). That is, when the model included alignment relative to the cranium, C2, and C7, greater or more anterior CrSVA-H resulted in worse SRS-22r scores, while smaller or more posterior CrSVA-H resulted in better scores. Similar models for subdomains again found CrSVA-H to be the best predictor of function (β = −0.0095, p < 0.0001), pain (β = −0.0091, p < 0.0001), self-image (β = −0.0084, p = 0.0004), and mental health (β = −0.0059, p = 0.0026). CONCLUSIONS In multivariable regression, C7 SVA was supplanted by CrSVA-H alignment as a significant, independent predictor of 2-year SRS-22r scores in patients with adult spinal deformity and should be considered as one of the standard postoperative sagittal alignment target goals.