An unpopular take but we teach sagittal alignment poorly(and many of us know better). Especially, on platforms like LinkedIn, we teach it as dogma and a set of static measurements based on shape, and standing alignment. We teach it while ignoring the patient's dynamic stances and postures. We often speak about other neurophysiologic parameters in passing. This leads to a very narrow view of the patient's alignment and leads to over-treatment and fusion of malaligned patients that are well-compensated and may have done, as well, with a lesser intervention.
To be clear, Sagittal balance, the 'Cone of Economy', and the spine's shape have to be respected and understood by physicians performing an instrumented spine intervention/fusion. And, I, vehemently, disagree with Spine surgeons and pain physicians that instrument the spine without accounting for the impact on the sagittal alignment or blanketly disregarding its impact.
However, I also believe that spinal deformity surgeons/educators don't spend the appropriate time to discuss the nuance and mode of failures that exist irrespective of sagittal parameters. An often underreported one is the underlying presence of neuropathology, Parkinson's or long-standing Diabetes are obvious ones but a substantial percentage of patients over the age of 70 have issues that are underreported or not diagnosed accurately.
