Which components of the global alignment proportionality score have the greatest impact on outcomes in adult spinal deformity corrective surgery?

To investigate the impact of the Global Alignment and Proportion (GAP) score components on patient outcomes in Adult Spine Deformity (ASD) surgery. Patients included underwent assessment via the GAP score and its individual components: pelvic version (GAP PV), lumbar lordosis (GAP LL), lumbar distribution index (GAP LDI) and spinopelvic component (GAP SP). Multivariable analyses assessed the association between alignment in these components and clinical outcomes in ASD patients. 762 ASD patients met inclusion criteria. Alignment in GAP SP independently predicted meeting MCID for SR-22S and ODI and was associated with a lower likelihood of developing mechanical complications. Patients aligned in GAP SP were less likely to develop proximal junctional kyphosis (OR 0.42, 0.26-0.73, p = 0.01) and PJF (OR 0.3, 0.13-0.74, p = 0.01). Proportioned alignment in GAP SP with disproportioned alignment in GAP LDI contributed to an increased risk of PJK and PJF (OR 2.67, 95% CI 1.95-6.82, p = 0.045). There was no significant association of GAP SP proportionality and GAP RPV (OR 1.1, 0.86-2.15, p = 0.253) or GAP LL (OR 1.34, 0.78-4.23, p = 0.673) disproportionality with outcomes. Disproportioned alignment in GAP SP but proportioned alignment in both GAP LL and GAP LDI was associated with decreased likelihood of PJK (OR 0.53, 95% CI 0.39-0.94, p = 0.02) and PJF (OR 0.31, 95% CI 0.19-0.67, p = 0.001). The spinopelvic component of the GAP score is the most significant independent predictor of clinical outcomes. Its interaction with the other components of the GAP score also aids assessment of the risk for mechanical complications.