Abstract Sagittal alignment is a critical component of the evaluation and management of adult spinal deformities. Loss of sagittal alignment may be the result of iatrogenic-induced deformity, metabolic bone problems, progression of idiopathic or neuromuscular deformities, posttraumatic, or de novo. Goals of reconstruction involve restoration of global sagittal balance and lumbopelvic harmony. Treating the deformity often involves long construct fusion to the sacropelvis. Often times, multilevel osteotomies as well as circumferential approaches are needed to adequately address the deformity. Failure to address sagittal plane deformities has been linked to poor patient reported outcomes from surgical management. However, even with correction, postoperative complications are common. These included proximal and distal junctional failure, pseudoarthrosis, and the need for future surgery.