Recent Advances in Adult Spinal Deformity

Abstract

The field is moving from radiograph-centered correction toward patient-specific, risk-adjusted reconstruction. The most consequential advances are not a single implant or approach, but the integration of age-and morphology-adjusted alignment, bone and muscle health, frailty-informed selection, less invasive circumferential strategies, proximal-junctional transition planning, and data-driven prediction. The evidence is strongest for comprehensive optimization and avoidance of overcorrection; many technologies remain promising but incompletely validated. Abstract: Adult spinal deformity (ASD) surgery can provide durable improvements in pain, disability, and health related quality of life, but it remains associated with major medical, neurologic, and mechanical complications. Recent development has therefore focused on improving value rather than maximizing correction. This narrative review synthesizes contemporary advances in diagnosis, patient selection, alignment planning, perioperative optimization, minimally invasive and hybrid reconstruction, osteotomy strategy, fixation and rod constructs, proximal junctional kyphosis/failure prevention, navigation and robotics, artificial intelligence, and recovery pathways. Alignment targets have evolved beyond fixed SRS Schwab thresholds to age-adjusted and proportional concepts, with increasing attention to pelvic morphology, lumbar shape, segmental lordosis, and whole-body compensation. Bone health, frailty, sarcopenia, cognition, and psychosocial vulnerability are now treated as modifiable or decision-shaping variables. Circumferential minimally invasive surgery, anterior column realignment, prone lateral access, and staged or single-position workflows can reduce approach morbidity in selected deformities, although severe rigid deformity still requires open posterior reconstruction or three-column osteotomy. Junctional prevention is increasingly multimodal, combining appropriate correction, soft-tissue preservation, transition rods or hooks, ligament augmentation, cement when indicated, and osteoporosis treatment. Robotics, navigation, automated radiographic measurement, and machine-learning models are expanding planning and execution, but external validation, calibration, explainability, and workflow economics remain limiting. The contemporary objective is a durable, physiologically tolerable reconstruction tailored to the patient's goals and failure risk.