SynthesisSpine deformity2026
L5 vs. pelvic fixation as the lowest instrumented vertebra in long-segment fusion for adult spinal deformity: a systematic review and meta-analysis.
Synthesis in Spine deformity, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Authors and funding
14 authors.
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Abstract
purposeTo compare radiographic outcomes, patient-reported outcomes (PROs), and complications between L5 and sacropelvic fixation as the lowest instrumented vertebra (LIV) in long-segment fusion for adult spinal deformity (ASD).
methodsFollowing PRISMA 2020 guidelines, PubMed, Web of Science, Scopus, and Embase were searched for studies comparing L5 vs. pelvic fixation in ASD. Studies with Newcastle-Ottawa Scale (NOS) ≥ 7 were included. Extracted data included demographics, radiographic parameters [pelvic tilt (PT), lumbar lordosis (LL), sagittal vertical axis (SVA)], complications, and PROs [Scoliosis Research Society (SRS) and Oswestry Disability Index (OD)]. Meta-analysis used standardized mean differences (SMD) and odds ratios (OR). Heterogeneity was assessed with I
resultsNine studies (1196 patients; mean age 67.5 years; mean follow-up 36.5 months) were included. Pelvic fixation achieved better sagittal correction: lower PT (SMD 0.88, p = 0.005), higher LL (SMD - 0.76, p < 0.001), and lower SVA (SMD 0.82, p = 0.016). PROs were similar at baseline and follow-up (all p > 0.05). L5 fixation had shorter operative time (SMD - 0.78, p = 0.005) but higher distal junctional failure (DJF) risk (OR 2.62, p = 0.002). Predictors of DJF with L5 LIV included older age, extensive fusion, high pelvic incidence, facet degeneration, and poor baseline sagittal balance.
conclusionsPelvic fixation provides superior sagittal correction with comparable PROs and overall complications, while L5 fixation carries a 2.6-fold higher DJF risk. LIV selection must be individualized; pelvic fixation is strongly recommended for patients with advanced age (> 66 years), high pelvic incidence (> 52°), or severe sagittal malalignment to mitigate mechanical failure. PROSPERO ID Number: CRD420251129518.
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