Purpose Spinal deformities and pathologies of the spinopelvic junction are conditions affecting up to 60-70 % of the general aging population. In this review, we discuss the more recent knowledge on sagittal balance and its clinical implications. Methods Review of the literature regarding global spine balance. Results Global spinal balance and its relationship to the pelvis correlate closely with disability and quality of life. It has been demonstrated that extensive surgery, previously considered to have poor balance between risks and outcomes, causes great improvements in health-related quality of life in the oldest age groups. Conclusion Failure to restore normal sagittal alignment in patients primarily operated for other than deformity results in unacceptable rates of poor results and revision surgery.