Pelvic and sacral morphology and their correlation with pelvic incidence, lumbar lordosis, and lumbar alignment changes between standing and sitting postures

OBJECTIVERadiculopathy from the fractional curve, usually from L3 to S1, can create severe disability. However, treatment methods of the curve vary. The authors evaluated the effect of adding more levels of interbody fusion during treatment of the fractional curve.METHODSA single-institution retrospective review of adult patients treated for scoliosis between 2006 and 2016 was performed. Inclusion criteria were as follows: fractional curves from L3 to S1 > 10°, ipsilateral radicular symptoms concordant on the fractional curve concavity side, patients who underwent at least 1 interbody fusion at the level of the fractional curve, and a minimum 1-year follow-up. Primary outcomes included changes in fractional curve correction, lumbar lordosis change, pelvic incidence − lumbar lordosis mismatch change, scoliosis major curve correction, and rates of revision surgery and postoperative complications. Secondary analysis compared the same outcomes among patients undergoing posterior, anterior, and lateral approaches for their interbody fusion.RESULTSA total of 78 patients were included. There were no significant differences in age, sex, BMI, prior surgery, fractional curve degree, pelvic tilt, pelvic incidence, pelvic incidence − lumbar lordosis mismatch, sagittal vertical axis, coronal balance, scoliotic curve magnitude, proportion of patients undergoing an osteotomy, or average number of levels fused among the groups. The mean follow-up was 35.8 months (range 12–150 months). Patients undergoing more levels of interbody fusion had more fractional curve correction (7.4° vs 12.3° vs 12.1° for 1, 2, and 3 levels; p = 0.009); greater increase in lumbar lordosis (−1.8° vs 6.2° vs 13.7°, p = 0.003); and more scoliosis major curve correction (13.0° vs 13.7° vs 24.4°, p = 0.01). There were no statistically significant differences among the groups with regard to postoperative complications (overall rate 47.4%, p = 0.85) or need for revision surgery (overall rate 30.7%, p = 0.25). In the secondary analysis, patients undergoing anterior lumbar interbody fusion (ALIF) had a greater increase in lumbar lordosis (9.1° vs −0.87° for ALIF vs transforaminal lumbar interbody fusion [TLIF], p = 0.028), but also higher revision surgery rates unrelated to adjacent-segment pathology (25% vs 4.3%, p = 0.046). Higher ALIF revision surgery rates were driven by rod fracture in the majority (55%) of cases.CONCLUSIONSMore levels of interbody fusion resulted in increased lordosis, scoliosis curve correction, and fractional curve correction. However, additional levels of interbody fusion up to 3 levels did not result in more postoperative complications or morbidity. ALIF resulted in a greater lumbar lordosis increase than TLIF, but ALIF had higher revision surgery rates.

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The utility of supine radiographs in the assessment of thoracic flexibility and risk of proximal junctional kyphosis

Journal of Neurosurgery Spine ◽

10.3171/2020.11.spine201565 ◽

2021 ◽

pp. 1-7

Author(s):

Francis Lovecchio ◽

Renaud Lafage ◽

Jonathan Charles Elysee ◽

Alex Huang ◽

Bryan Ang ◽

...

Keyword(s):

Thoracic Spine ◽

Lumbar Lordosis ◽

Pelvic Tilt ◽

Pelvic Incidence ◽

Vertical Axis ◽

Control Analysis ◽

Proximal Junctional Kyphosis ◽

Sagittal Vertical Axis ◽

Significant Difference ◽

Junctional Kyphosis

OBJECTIVE Supine radiographs have successfully been used for preoperative planning of lumbar deformity corrections. However, they have not been used to assess thoracic flexibility, which has recently garnered attention as a potential contributor to proximal junctional kyphosis (PJK). The purpose of this study was to compare supine to standing radiographs to assess thoracic flexibility and to determine whether thoracic flexibility is associated with PJK. METHODS A retrospective study was conducted of a single-institution database of patients with adult spinal deformity (ASD). Sagittal alignment parameters were compared between standing and supine and between pre- and postoperative radiographs. Thoracic flexibility was determined as the change between preoperative standing thoracic kyphosis (TK) and preoperative supine TK, and these changes were measured over the overall thoracic spine and the fused portion of the thoracic spine (i.e., TK fused). A case-control analysis was performed to compare thoracic flexibility between patients with PJK and those without (no PJK). The cohort was also stratified into three groups based on thoracic flexibility: kyphotic change (increased TK), lordotic change (decreased TK), and no change. The PJK rate was compared between the cohorts. RESULTS A total of 101 patients (mean 63 years old, 82.2% female, mean BMI 27.4 kg/m2) were included. Preoperative Scoliosis Research Society–Schwab ASD classification showed moderate preoperative deformity (pelvic tilt 27.7% [score ++]; pelvic incidence–lumbar lordosis mismatch 44.6% [score ++]; sagittal vertical axis 42.6% [score ++]). Postoperatively, the average offset from age-adjusted alignment goals demonstrated slight overcorrection in the study sample (−8.5° ± 15.6° pelvic incidence–lumbar lordosis mismatch, −29.2 ± 53.1 mm sagittal vertical axis, −5.4 ± 10.8 pelvic tilt, and −7.6 ± 11.7 T1 pelvic angle). TK decreased between standing and supine radiographs and increased postoperatively (TK fused: −25.3° vs −19.6° vs −29.9°; all p < 0.001). The overall rate of radiographic PJK was 23.8%. Comparisons between PJK and no PJK demonstrated that offsets from age-adjusted alignment goals were similar (p > 0.05 for all). There was a significant difference in the PJK rate when stratified by thoracic flexibility cohorts (kyphotic: 0.0% vs no change: 18.4% vs lordotic: 35.0%; p = 0.049). Logistic regression revealed thoracic flexibility (p = 0.045) as the only independent correlate of PJK. CONCLUSIONS Half of patients with ASD experienced significant changes in TK during supine positioning, a quality that may influence surgical strategy. Increased thoracic flexibility is associated with PJK, possibly secondary to fusing the patient’s spine in a flattened position intraoperatively.

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Normal Age-Adjusted Sagittal Spinal Alignment Is Achieved with Surgical Correction in Adolescent Idiopathic Scoliosis

Asian Spine Journal ◽

10.4184/asj.2017.11.5.770 ◽

2017 ◽

Vol 11 (5) ◽

pp. 770-779 ◽

Cited By ~ 1

Author(s):

Subaraman Ramchandran ◽

Norah Foster ◽

Akhila Sure ◽

Thomas J. Errico ◽

Aaron J. Buckland

Keyword(s):

Adolescent Idiopathic Scoliosis ◽

Idiopathic Scoliosis ◽

Lumbar Lordosis ◽

Thoracic Kyphosis ◽

Pelvic Incidence ◽

Sagittal Alignment ◽

Vertical Axis ◽

Surgical Correction ◽

Sagittal Vertical Axis

<sec><title>Study Design</title>Retrospective analysis.</sec><sec><title>Purpose</title>Our hypothesis is that the surgical correction of adolescent idiopathic scoliosis (AIS) maintains normal sagittal alignment as compared to age-matched normative adolescent population.</sec><sec><title>Overview of Literature</title>Sagittal spino-pelvic alignment in AIS has been reported, however, whether corrective spinal fusion surgery re-establishes normal alignment remains unverified.</sec><sec><title>Methods</title>Sagittal profiles and spino-pelvic parameters of thirty-eight postsurgical correction AIS patients ≤21 years old without prior fusion from a single institution database were compared to previously published normative age-matched data. Coronal and sagittal measurements including structural coronal Cobb angle, pelvic incidence, pelvic tilt, thoracic kyphosis, lumbar lordosis, sagittal vertical axis, C2–C7 cervical lordosis, C2–C7 sagittal vertical axis, and T1 pelvic angles were measured on standing full-body stereoradiographs using validated software to compare preoperative and 6 months postoperative changes with previously published adolescent norms. A sub-group analysis of patients with type 1 Lenke curves was performed comparing preoperative to postoperative alignment and also comparing this with previously published normative values.</sec><sec><title>Results</title>The mean coronal curve of the 38 AIS patients (mean age, 16±2.2 years; 76.3% female) was corrected from 53.6° to 9.6° (80.9%, <italic>p</italic><0.01). None of the thoracic and spino-pelvic sagittal parameters changed significantly after surgery in previously hypo- and normo-kyphotic patients. In hyper-kyphotic patients, thoracic kyphosis decreased (<italic>p</italic>=0.003) with a reciprocal decrease in lumbar lordosis (<italic>p</italic>=0.01), thus lowering pelvic incidence-lumbar lordosis mismatch mismatch (<italic>p</italic>=0.009). Structural thoracic scoliosis patients had slightly more thoracic kyphosis than age-matched patients at baseline and surgical correction of the coronal plane of their scoliosis preserved normal sagittal alignment postoperatively. A sub-analysis of Lenke curve type 1 patients (n=24) demonstrated no statistically significant changes in the sagittal alignment postoperatively despite adequate coronal correction.</sec><sec><title>Conclusions</title>Surgical correction of the coronal plane in AIS patients preserves sagittal and spino-pelvic alignment as compared to age-matched asymptomatic adolescents.</sec>

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Lumbar lordosis does not correlate with pelvic incidence in the cases with the lordosis apex located at L3 or above

European Spine Journal ◽

10.1007/s00586-018-5695-9 ◽

2018 ◽

Vol 28 (9) ◽

pp. 1948-1954 ◽

Cited By ~ 4

Author(s):

Osamu Tono ◽

Kazuhiro Hasegawa ◽

Masashi Okamoto ◽

Shun Hatsushikano ◽

Haruka Shimoda ◽

...

Keyword(s):

Lumbar Lordosis ◽

Pelvic Incidence

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Revision Strategies for Harrington Rod Instrumentation: Radiographic Outcomes and Complications

Global Spine Journal ◽

10.1177/2192568220960759 ◽

2020 ◽

pp. 219256822096075

Author(s):

Philip K. Louie ◽

Sravisht Iyer ◽

Krishn Khanna ◽

Garrett K. Harada ◽

Alina Khalid ◽

...

Keyword(s):

Adolescent Idiopathic Scoliosis ◽

Idiopathic Scoliosis ◽

Revision Surgery ◽

Lumbar Lordosis ◽

Pelvic Incidence ◽

Vertical Axis ◽

Sagittal Vertical Axis ◽

Radiographic Outcomes ◽

Harrington Rod

Study Design: Retrospective case series. Objective: The purpose of this study is to evaluate the clinical and radiographic outcomes following revision surgery following Harrington rod instrumentation. Methods: Patients who underwent revision surgery with a minimum of 1-year follow-up for flatback syndrome following Harrington rod instrumentation for adolescent idiopathic scoliosis were identified from a multicenter dataset. Baseline demographics and intraoperative information were obtained. Preoperative, initial postoperative, and most recent spinopelvic parameters were compared. Postoperative complications and reoperations were subsequently evaluated. Results: A total of 41 patients met the inclusion criteria with an average follow-up of 27.7 months. Overall, 14 patients (34.1%) underwent a combined anterior-posterior fusion, and 27 (65.9%) underwent an osteotomy for correction. Preoperatively, the most common lower instrumented vertebra (LIV) was at L3 and L4 (61%), whereas 85% had a LIV to the pelvis after revision. The mean preoperative pelvic incidence–lumbar lordosis mismatch and C7 sagittal vertical axis were 23.7° and 89.6 mm. This was corrected to 8.1° and 28.9 mm and maintained to 9.04° and 34.4 mm at latest follow-up. Complications included deep wound infection (12.2%), durotomy (14.6%), implant related failures (14.6%), and temporary neurologic deficits (22.0%). Eight patients underwent further revision surgery at an average of 7.4 months after initial revision. Conclusions: There are multiple surgical techniques to address symptomatic flatback syndrome in patients with previous Harrington rod instrumentation for adolescent idiopathic scoliosis. At an average of 27.7 months follow-up, pelvic incidence–lumbar lordosis mismatch and C7 sagittal vertical axis can be successfully corrected and maintained. However, complication and reoperation rates remain high.

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Morphology, pathology, and the vertebral posture of the La Chapelle-aux-Saints Neandertal

Proceedings of the National Academy of Sciences ◽

10.1073/pnas.1820745116 ◽

2019 ◽

Vol 116 (11) ◽

pp. 4923-4927 ◽

Cited By ~ 6

Author(s):

Martin Haeusler ◽

Erik Trinkaus ◽

Cinzia Fornai ◽

Jonas Müller ◽

Noémie Bonneau ◽

...

Keyword(s):

Lumbar Lordosis ◽

Pelvic Incidence ◽

Cervical Vertebrae ◽

Functional Anatomy ◽

Spinal Curvatures ◽

Lower Back ◽

Age Related ◽

Form Part ◽

Spinal Imbalance ◽

Lower Lumbar

Although the early postural reconstructions of the Neandertals as incompletely erect were rejected half a century ago, recent studies of Neandertal vertebral remains have inferred a hypolordotic, flat lower back and spinal imbalance for them, including the La Chapelle-aux-Saints 1 skeleton. These studies form part of a persistent trend to view the Neandertals as less “human” than ourselves despite growing evidence for little if any differences in basic functional anatomy and behavioral capabilities. We have therefore reassessed the spinal posture of La Chapelle-aux-Saints 1 using a new pelvic reconstruction to infer lumbar lordosis, interarticulation of lower lumbar (L4-S1) and cervical (C4-T2) vertebrae, and consideration of his widespread age-related osteoarthritis. La Chapelle-aux-Saints 1 exhibits a pelvic incidence (and hence lumbar lordosis) similar to modern humans, articulation of lumbar and cervical vertebrae indicating pronounced lordosis, and Baastrup disease as a product of his advanced age, osteoarthritis, and lordosis. Our findings challenge the view of generally small spinal curvatures in Neandertals. Setting aside the developmentally abnormal Kebara 2 vertebral column, La Chapelle-aux-Saints 1 is joined by other Neandertals with sufficient vertebral remains in providing them with a fully upright (and human) axial posture.

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Letter to the Editor concerning “Correlation between the apex of lumbar lordosis and pelvic incidence in asymptomatic adult” by Pan C, et al. (Eur Spine J (2020); 29(3): DOI 10.1007/s00586-019-06183-y)

European Spine Journal ◽

10.1007/s00586-020-06428-1 ◽

2020 ◽

Vol 29 (7) ◽

pp. 1780-1781

Author(s):

Amer Sebaaly ◽

Pierre Roussouly

Keyword(s):

Lumbar Lordosis ◽

Pelvic Incidence ◽

Letter To The Editor ◽

Asymptomatic Adult

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Supine Imaging Is a Superior Predictor of Long-Term Alignment Following Adult Spinal Deformity Surgery

Global Spine Journal ◽

10.1177/2192568220960753 ◽

2020 ◽

pp. 219256822096075

Author(s):

Jonathan Charles Elysee ◽

Francis Lovecchio ◽

Renaud Lafage ◽

Bryan Ang ◽

Alex Huang ◽

...

Keyword(s):

Spinal Deformity ◽

Lumbar Lordosis ◽

Pelvic Incidence ◽

Lumbar Fusion ◽

Adult Spinal Deformity ◽

Multilinear Regression ◽

Sagittal Vertical Axis ◽

Type Curve ◽

Scoliosis Research Society ◽

Correlation Analyses

Study Design: Retrospective cohort study. Objective: To investigate correlations between preoperative supine imaging and postoperative alignment. Methods: A retrospective review was conducted of a single-institution database of patients with adult spinal deformity (ASD). Patients were stratified by fusion location in the lumbar or thoracic spine. Outcomes of interest were postoperative lumbar lordosis (LL) and thoracic kyphosis (TK). Sagittal alignment parameters were compared and correlation analyses were performed. Multilinear stepwise regression was conducted to identify independent predictors of postoperative LL or TK. Regression analyses were repeated within the lumbar and thoracic fusion cohorts. Results: A total of 99 patients were included (mean age 63.2 years, 83.1% female, mean body mass index 27.3 kg/m2). Scoliosis Research Society classification demonstrated moderate to severe sagittal and/or coronal deformity (pelvic tile modifier, 18.2% ++; sagittal vertical axis, 27.3% ++, pelvic incidence minus lumbar lordosis mismatch, 29.3% ++, SRS type, 29.3% N type curve and 68.7% L or D type curve). A total of 73 patients (73.7%) underwent lumbar fusion and 50 (50.5%) underwent thoracic fusion. Correlation analyses demonstrated a significant association between pre- and postoperative LL and TK. Multilinear regression demonstrated that LL supine and pelvic incidence were significant predictors of postoperative LL ( r 2 = 0.568, P < .001). LL supine, TK supine, and age were significant predictors of postoperative TK ( r 2 = 0.490, P < .001). Conclusion: Preoperative supine films are superior to standing in predicting postoperative alignment at 1-year follow-up. Anticipation of undesired alignment changes through supine imaging may be useful in mitigating the risk of iatrogenic malalignment.

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