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Purpose: Highlight risk factors for pseudarthrosis in long-segment spinal fusions, collect the approaches carried to address this complication. Methods: Patients with ASD and fusion of ≥ 4 levels with minimum follow-up (FU) of ≥ 2 years were included. Full-body X-rays were done preoperatively, < 3 months and ≥ 2 years. Oswestry disability index (ODI), Scoliosis Research Society-22 and SF36 assessed pre- and postoperatively. The relationship between demographic, surgical and radiological variables with the development of pseudarthrosis was evaluated. Results: Out of 524 patients included, 65 patients (12.4%) developed pseudarthrosis and 53 underwent revision surgery. Notably, 88% of pseudarthrosis cases are associated with fusion length (OR = 1.17, 95% CI = 1.05–1.292, p = 0.004), osteotomy requirement (OR = 0.28, 95% CI = 0.09–0.85, p = 0.025), pelvic fixation (OR = 0.34, 95% CI = 0.13–0.88, p = 0.026) and combined approaches (OR = 3.29, 95% CI = 1.09–9.91, p = 0.034). Sagittal alignment is not related to the rate of pseudarthrosis. Health related and quality of life scores were comparable at last FU between patients revised for pseudarthrosis and those that didn't require revision surgery (ODI = 28% no revision and 30% revision group). Conclusions: Pseudarthrosis is not related to malalignment, but with the surgical techniques employed for its treatment. Anterior approaches with anterior support decrease the rate by 30%, while long fusions, osteotomies and pelvic fixation increase its rate. [ABSTRACT FROM AUTHOR]