Warning: fopen(/home/virtual/e-kjs/journal/upload/ip_log_2021-10.txt): failed to open stream: Permission denied in /home/virtual/lib/view_data.php on line 73 Warning: fwrite() expects parameter 1 to be resource, boolean given in /home/virtual/lib/view_data.php on line 74 Commentary on “Modified Global Alignment and Proportion Scoring With Body Mass Index and Bone Mineral Density Analysis in Global Alignment and Proportion Score of Each 3 Categories for Predicting Mechanical Complications After Adult Spinal Deformity Surgery”
Neurospine Search


Neurospine > Volume 18(3); 2021 > Article
Chou: Commentary on “Modified Global Alignment and Proportion Scoring With Body Mass Index and Bone Mineral Density Analysis in Global Alignment and Proportion Score of Each 3 Categories for Predicting Mechanical Complications After Adult Spinal Deformity Surgery”
The authors have performed a retrospective review of 203 patients who underwent adult spinal deformity (ASD) surgery with minimum 2-year follow-up [1]. The authors have analyzed the global alignment and proportion (GAP) score, incorporating bone mineral density (BMD) and body mass index (BMI). The authors found that when incorporating BMI and BMI into the GAP score (GAPB), the GAPB score correlates with mechanical failure in patients when they are moderately or severe disproportioned in their alignment.
I commend the authors for their work in incorporating BMI and BMD into the evaluation of mechanical failures in ASD surgery. This represents important work because Bari et al. [2] had reported that the GAP score alone—without the incorporation of BMI and BMD—has been unable to predict mechanical failure in ASD patients undergoing 4 or more levels of fusion. However, the original GAP score alone does not incorporate the BMI and BMD. Many mechanical failures can be related to poor bone quality because of the implant-bone junction interface failure. In our practice, all patient’s bone densities are check prior to any fusion surgery, and by incorporating bone density into decision making, we have anecdotally seen fewer screw pull-out failures. Thus, it makes sense that the current authors’ findings of incorporating BMD in the form of the GAPB score create a more accurate predictor of mechanical failure. In addition, the incorporation of BMI as a predictor makes sense. In patients with high BMI, the failure of mainly posterior-based constructs in the face of significant anterior trunk weight can potentially be predicted using the GAPB score instead of the GAP score. By incorporating BMI and BMD into the GAP score, the current authors have shown that incorporation of these 2 elements has made the GAP score more accurate by converting it into the GAPB score.
The original GAP score takes into account age, pelvic incidence, sacral slope (SS), L4–S1 lordosis, L1–S1 lordosis, and the global tilt, as measured from C7 down to the sacrum [3]. However, the reliability and accuracy of the GAP score alone have been called into question. Kwan et al. [4] have recently reported that a higher GAP score does not predict mechanical complications after ASD surgery using 272 patients from the Scoli-RISK-1 prospective trial data. As mentioned above, Bari et al. [2] also could not find an association with the GAP score and mechanical complications. Given that large studies could not find a direct correlation with the GAP score and mechanical complications, the study performed by the current authors sheds new light and insight onto the GAP score. The current authors’ inclusion of BMI and bone density add 2 very important factors that were not originally included in the GAP score. Increasingly, it is becoming clear that bone density is a very important factor in spinal fusion, not just in deformity cases, but also in degenerative conditions. In addition, it makes sense that BMI also plays an important role given the primarily posterior-based support structure in most adult deformity surgery. It stands to reason that a patient with a high BMI and low bone density may have a higher mechanical failure rate than a patient who has a low BMI with high bone density. The authors have taken these 2 factors into consider, improving upon the GAP score.
Another consideration that may be useful in the prevention of mechanical failure is taking into consideration the Roussouly type, spinal shape, and location of the 3-column osteotomy, if performed [5]. Pizones et al. [6] showed that placing the pedicle subtraction osteotomy at the natural apex of the Roussouly type was associated with a lower rate of mechanical failure. Based upon this finding, the natural shape of the spine based upon the Roussouly type should ideally be recreated if possible. This may also be a very important factor in patients who are Roussouly types I and II (SS less than 35°). These low Roussouly type patients may not be amenable to large amounts of lordosis induction because of the low SS. Such patients may live with relatively flat backs, and induction of large amounts of lordosis in such patients may increase the propensity for proximal junctional kyphosis (PJK). Xi et al. [7] showed that as the L1 vertebral body is posteriorly displaced relative to the gravity line, there is an increased risk of PJK. This is consistent with potential over induction of lordosis in low Roussouly type patients with concomitant dorsal L1 displacement. This significant posterior L1 displacement results in reciprocal hyper-kyphosis at the thoracolumbar junction or at the thoracic spine in order for the patient to maintain neutral a sagittal vertical axis. It is this reciprocal kyphosis that results in increased stress at or above the upper instrumented vertebra. This increased stress may result in PJK. This combination of a low Roussouly type and over induction of lordosis may be one contribution to PJK.
The authors of this manuscript have done a nice job of showing that the incorporation of BMI and bone density into the GAP score increases the GAP score’s validity. This study provides support to the notion that PJK has a multifactorial etiology. It is the totality of these factors that need to be considered, not simply the radiographic measurements. I commend the authors of taking the GAP score to the next level to improve and validate its utility with the incorporation of these non-radiographic elements.


The author has nothing to disclose.


1. Noh SH, Ha Y, Park JY, et al. Modified global alignment and proportion scoring with body mass index and bone mineral density analysis in global alignment and proportion score of each 3 categories for predicting mechanical complications after adult spinal deformity surgery. Neurospine 2021;18:484-91.
2. Bari TJ, Ohrt-Nissen S, Hansen LV, et al. Ability of the global alignment and proportion score to predict mechanical failure following adult spinal deformity surgery-validation in 149 patients with two-year follow-up. Spine Deform 2019;7:331-7.
crossref pmid
3. Yilgor C, Sogunmez N, Boissiere L, et al. Global alignment and proportion (GAP) score: development and validation of a new method of analyzing spinopelvic alignment to predict mechanical complications after adult spinal deformity surgery. J Bone Joint Surg Am 2017;99:1661-72.
crossref pmid
4. Kwan KYH, Lenke LG, Shaffrey CI, et al. Are higher global alignment and proportion scores associated with increased risks of mechanical complications after adult spinal deformity surgery? An external validation. Clin Orthop Relat Res 2021;479:312-20.
crossref pmid
5. Roussouly P, Gollogly S, Berthonnaud E, et al. Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine (Phila Pa 1976) 2005;30:346-53.
crossref pmid
6. Pizones J, Perez-Grueso FJS, Moreno-Manzanaro L, et al. Ideal sagittal profile restoration and ideal lumbar apex positioning play an important role in postoperative mechanical complications after a lumbar PSO. Spine Deform 2020;8:491-8.
crossref pmid
7. Xi Z, Duan PG, Mummaneni PV, et al. Posterior displacement of L1 may be a risk factor for proximal junctional kyphosis after adult spinal deformity correction. Global Spine J 2021 May 17:21925682211015651. https://doi.org/10.1177/21925682211015651. [Epub].

Editorial Office
Department of Neurosurgery, Yonsei University College of Medicine
50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea
Tel: +82-2-2228-2158  E-mail: theneurospine@gmail.com
The Korean Spinal Neurosurgery Society
#407, Dong-A Villate 2nd Town, 350 Seocho-daero, Seocho-gu, Seoul 06631, Korea
Tel: +82-2-585-5455  Fax: +82-2-2-523-6812  E-mail: ksns1987@gmail.com
Business License No.: 209-82-62443

Copyright © The Korean Spinal Neurosurgery Society.

Developed in M2PI

Close layer
prev next