Spinopelvic Sagittal Alignment after Microendoscopic Laminotomy in Patients with Lumbar Degenerative Spondylolisthesis

Background and Study Aims Spinopelvic sagittal balance is important in managing lumbar diseases. We evaluated the change in spinal sagittal alignment after microendoscopic laminotomy in patients with low-grade degenerative spondylolisthesis (DS). Material and Methods We retrospectively reviewed the records of 87 patients who underwent microendoscopic laminotomy. We enrolled 35 patients with DS and 52 patients without DS. Spinopelvic parameters were evaluated, including the sagittal vertical axis (SVA), lumbar lordosis (LL), sacral slope, pelvic tilt, and pelvic incidence (PI). Primary outcome was a change in spinopelvic alignment between the baseline and latest follow-up values (DS group versus non-DS group). Secondary outcomes were the relationships between improved global sagittal alignment and preoperative spinopelvic parameters. Results Both groups showed significantly alleviated low back pain (LBP), leg pain, and leg numbness. Preoperative SVA and PI were significantly higher in the DS group than in the non-DS group (p < 0.05). SVA significantly decreased and LL significantly increased in the DS group (p < 0.05), whereas those parameters did not differ significantly from before versus after surgery in the non-DS group. In both groups, SVA improvement correlated significantly with preoperative SVA (DS: r = 0.702; non-DS: r = 0.397). There was also a significant intergroup difference in the correlation coefficient (z = 1.98; r = 0.048). Conclusions SVA and LL significantly improved after microscopic laminotomy in patients with low-grade DS and neurologic symptoms. SVA improvement in the DS group was correlated with preoperative spinopelvic sagittal imbalance. The strength of those correlations was greater in the DS group than in the non-DS group.

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Implications of Spinopelvic Alignment for the Spine Surgeon

Neurosurgery ◽

10.1227/neu.0b013e31823262ea ◽

2011 ◽

Vol 70 (3) ◽

pp. 707-721 ◽

Cited By ~ 55

Author(s):

Vivek A. Mehta ◽

Anubhav Amin ◽

Ibrahim Omeis ◽

Ziya L. Gokaslan ◽

Oren N. Gottfried

Keyword(s):

Sagittal Balance ◽

Lumbar Lordosis ◽

Pelvic Incidence ◽

Degenerative Spondylolisthesis ◽

Disease Process ◽

Sacral Slope ◽

Sagittal Imbalance ◽

Spinopelvic Parameters ◽

Spinopelvic Alignment ◽

Spinopelvic Balance

Abstract The relation of the pelvis to the spine has previously been overlooked as a contributor to sagittal balance. However, it is now recognized that spinopelvic alignment is important to maintain an energy-efficient posture in normal and disease states. The pelvis is characterized by an important anatomic landmark, the pelvic incidence (PI). The PI does not change after adolescence, and it directly influences pelvic alignment, including the parameters of pelvic tilt (PT) and sacral slope (SS) (PI = PT 1 SS), overall sagittal spinal balance, and lumbar lordosis. In the setting of an elevated PI, the spineadapts with increased lumbar lordosis. To prevent or limit sagittal imbalance, the spine may also compensate with increased PT or pelvic retroversion to attempt to maintain anupright posture. Abnormal spinopelvic parameters contribute to multiple spinal conditions including isthmic spondylolysis, degenerative spondylolisthesis, deformity, and impact outcome after spinal fusion. Sagittal balance, pelvic incidence, and all spinopelvic parameters are easily and reliably measured on standing, full-spine (lateral) radiographs, and it is essential to accurately assess and measure these sagittal values to understand their potential role in the disease process, and to promote spinopelvic balance at surgery. In this article, we provide a comprehensive review of the literature regarding the implications of abnormal spinopelvic parameters and discuss surgical strategies for correction of sagittal balance. Additionally, the authors rate and critique the quality of the literature cited in a systematic review approach to give the reader an estimate of the veracity of the conclusions reached from these reports.

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Implications of Spinopelvic Alignment for the Spine Surgeon

Neurosurgery ◽

10.1227/01.neu.0000462077.50830.1a ◽

2011 ◽

Vol 76 (suppl_1) ◽

pp. S42-S56 ◽

Cited By ~ 29

Author(s):

Vivek A. Mehta ◽

Anubhav Amin ◽

Ibrahim Omeis ◽

Ziya L. Gokaslan ◽

Oren N. Gottfried

Keyword(s):

Sagittal Balance ◽

Lumbar Lordosis ◽

Pelvic Incidence ◽

Degenerative Spondylolisthesis ◽

Disease Process ◽

Sacral Slope ◽

Sagittal Imbalance ◽

Spinopelvic Parameters ◽

Spinopelvic Alignment ◽

Spinopelvic Balance

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Influence of postoperative sagittal balance and spinopelvic parameters on the outcome of patients surgically treated for degenerative lumbar spondylolisthesis

Journal of Neurosurgery Spine ◽

10.3171/2016.9.spine1680 ◽

2017 ◽

Vol 26 (4) ◽

pp. 448-453 ◽

Cited By ~ 17

Author(s):

Ingrid Radovanovic ◽

Jennifer C. Urquhart ◽

Venkat Ganapathy ◽

Fawaz Siddiqi ◽

Kevin R. Gurr ◽

...

Keyword(s):

Outcome Measures ◽

Sagittal Balance ◽

Sagittal Alignment ◽

Degenerative Spondylolisthesis ◽

Consecutive Series ◽

Spinopelvic Parameters ◽

Degenerative Lumbar Spondylolisthesis ◽

Global Sagittal Alignment ◽

Lumbar Degenerative Spondylolisthesis ◽

Multiple Levels

OBJECTIVE The object of this study was to determine the association between postoperative sagittal spinopelvic alignment and patient-rated outcome measures following decompression and fusion for lumbar degenerative spondylolisthesis. METHODS The authors identified a consecutive series of patients who had undergone surgery for lumbar degenerative spondylolisthesis between 2008 and 2012, with an average follow-up of 3 years (range 1–6 years). Surgery was performed to address the clinical symptoms of spinal stenosis, not global sagittal alignment. Sagittal alignment was only assessed postoperatively. Patients were divided into 2 groups based on a postoperative sagittal vertical axis (SVA) < 50 mm (well aligned) or ≥ 50 mm (poorly aligned). Baseline demographic, procedure, and outcome measures were compared between the groups. Postoperative outcome measures and postoperative spinopelvic parameters were compared between groups using analysis of covariance. RESULTS Of the 84 patients included in this study, 46.4% had an SVA < 50 mm. Multiple levels of spondylolisthesis (p = 0.044), spondylolisthesis at the L3–4 level (p = 0.046), and multiple levels treated with fusion (p = 0.028) were more common among patients in the group with an SVA ≥ 50 mm. Patients with an SVA ≥ 50 mm had a worse SF-36 physical component summary (PCS) score (p = 0.018), a worse Oswestry Disability Index (ODI; p = 0.043), and more back pain (p = 0.039) than those with an SVA < 50 mm after controlling for multiple levels of spondylolisthesis and multilevel fusion. The spinopelvic parameters differing between the < 50-mm and ≥ 50-mm groups included lumbar lordosis (LL; 56.4° ± 4.7° vs 49.8° ± 4.3°, respectively, p = 0.040) and LL < pelvic incidence ± 9° (51% vs 23.1%, respectively, p = 0.013) after controlling for type of surgical procedure. CONCLUSIONS Data in this study revealed that patient-rated outcome is influenced by the overall postoperative sagittal balance as defined by the SVA.

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Lumbar Level Significantly Influences Postoperative Global Sagittal Balance Following Pedicle Subtraction Osteotomy

Global Spine Journal ◽

10.1177/21925682211032563 ◽

2021 ◽

pp. 219256822110325

Author(s):

Athan G. Zavras ◽

T. Barrett Sullivan ◽

Navya Dandu ◽

Howard S. An ◽

Christopher J. DeWald ◽

...

Keyword(s):

Sagittal Balance ◽

Sagittal Alignment ◽

Adult Spinal Deformity ◽

Vertical Axis ◽

Pedicle Subtraction Osteotomy ◽

Current Evidence ◽

Sacral Slope ◽

Sagittal Vertical Axis ◽

Lumbar Level ◽

Global Sagittal Alignment

Study Design: Retrospective cohort study. Objectives: The current evidence regarding how level of lumbar pedicle subtraction osteotomy (PSO) influences correction of sagittal alignment is limited. This study sought to investigate the relationship of lumbar level and segmental angular change (SAC) of PSO with the magnitude of global sagittal alignment correction. Methods: This study retrospectively evaluated 53 consecutive patients with adult spinal deformity who underwent lumbar PSO at a single institution. Radiographs were evaluated to quantify the effect of PSO on lumbar lordosis (LL), thoracic kyphosis (TK), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), T1-spinopelvic inclination (T1SPI), T1-pelvic alignment (TPA), and sagittal vertical axis (SVA). Results: Significant correlations were found between PSO SAC and the postoperative increase in LL ( r = 0.316, P = .021) and PT ( r = 0.352, P = .010), and a decrease in TPA ( r = −0.324, P = .018). PSO level significantly correlated with change in T1SPI ( r = −0.305, P = .026) and SVA ( r = −0.406, P = .002), with more caudal PSO corresponding to a greater correction in sagittal balance. On multivariate analysis, more caudal PSO level independently predicted a greater reduction in T1SPI (β = −3.138, P = .009) and SVA (β = −29.030, P = .001), while larger PSO SAC (β = −0.375, P = .045) and a greater number of fusion levels (β = −1.427, P = .036) predicted a greater reduction in TPA. Conclusion: This study identified a gain of approximately 3 degrees and 3 cm of correction for each level of PSO more caudal to L1. Additionally, a larger PSO SAC predicted greater improvement in TPA. While further investigation of these relationships is warranted, these findings may help guide preoperative PSO level selection.

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Usefulness of anterior column release for segmental lordosis restoration in degenerative lumbar kyphosis

Journal of Neurosurgery Spine ◽

10.3171/2021.5.spine202196 ◽

2021 ◽

pp. 1-7

Author(s):

Jin-Sung Park ◽

Chong-Suh Lee ◽

Youn-Taek Choi ◽

Se-Jun Park

Keyword(s):

Sagittal Alignment ◽

Adult Spinal Deformity ◽

Anterior Column ◽

Sacral Slope ◽

High Morbidity ◽

Global Sagittal Alignment ◽

The Mean ◽

Lumbar Kyphosis ◽

Segmental Lordosis

OBJECTIVE Three-column osteotomies (3COs) for surgical correction of lumbar kyphosis show a strong correction capacity, but this procedure carries high morbidity rates. The anterior column release (ACR) technique was developed as a less invasive procedure. In this study the authors aimed to evaluate sagittal alignment restoration using ACR and to determine factors that affect the degree of correction. METHODS This study included 36 patients (68 cases) who underwent ACR of more than one level for adult spinal deformity. Parameters for regional sagittal alignment included segmental lordosis (SL). The parameters for global sagittal alignment included pelvic incidence, lumbar lordosis, sacral slope, pelvic tilt, and sagittal vertical axis (SVA). In addition, the interdiscal height (IDH) and difference of interdiscal angle (DIDA) were measured to evaluate the stiffness of the vertebra segment. The changes in SL were evaluated after ACR and the change of global sagittal alignment was also determined. Factors such as the location of the ACR level, IDH, DIDA, cage height, and additional posterior column osteotomy (PCO) were analyzed for correlation with the degree of SL correction. RESULTS Thirty-six patients were included in this study. A total of 68 levels were operated with the ACR (8 levels at L2–3, 27 levels at L3–4, and 33 levels at L4–5). ACR was performed for 1 level in 10 patients, 2 levels in 20, and 3 levels in 6 patients (mean 1.9 ± 0.7 levels per patient). Mean follow-up duration was 27.1 ± 4.2 months. The mean SL of the total segment was 0.4° ± 7.2° preoperatively and increased by 15.3° ± 5.5° at the last follow-up (p < 0.001); thus, the mean increase of SL was 14.9° ± 8.1° per one ACR. Global sagittal alignment was also improved following SL restoration with SVA from 101.9 mm to 31.4 mm. The degree of SL correction was correlated with the location of ACR level (p = 0.041) and was not correlated with IDH, DIDA, cage height and additional PCO. CONCLUSIONS This study demonstrated that the mean correction angle of SL was 14.9 per one ACR. The degree of disc space collapse and stiffness of segment did not affect the degree of correction by ACR.

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Spinal sagittal alignment and head control in patients with cerebral palsy

Journal of Children s Orthopaedics ◽

10.1302/1863-2548.14.190160 ◽

2020 ◽

Vol 14 (1) ◽

pp. 17-23 ◽

Cited By ~ 1

Author(s):

Brice Ilharreborde ◽

Adrien de Saint Etienne ◽

Ana Presedo ◽

Anne-Laure Simon

Keyword(s):

Cerebral Palsy ◽

Sagittal Alignment ◽

Vertical Axis ◽

Sacral Slope ◽

Trunk Control ◽

Level Of Evidence ◽

Sagittal Vertical Axis ◽

Spinal Sagittal Alignment ◽

Trunk Posture ◽

Radiological Analysis

Purpose Spinal sagittal alignment restoration has been associated with improved functional outcomes and with reduced complications rates. Several limitations exist for radiological analysis in cerebral palsy (CP) patients. The goal of this study was to summarize the existing literature and report the important considerations to evaluate in a CP patient undergoing spinal surgery. Methods A retrospective radiological analysis was performed, including non-ambulant CP children with progressive scoliosis. Full-spine sitting radiographs performed pre-and postoperatively were required to measure spino-pelvic sagittal parameters. Result A total of 23 non-ambulating CP patients were included, mean age 16.0 years (standard error of the mean 0.5). Two distinct groups of patients were identified. Group 1 (61%) were patients with less trunk control (lumbar lordosis (LL) < 50°), retroverted and vertical pelvis (mean sacral slope (SS) 11.4° and pelvic tilt (PT) 38.1°) and anterior imbalance (mean sagittal vertical axis (SVA) 5.9 cm) and Group 2 (39%) were patients with better trunk control (LL > 60°, anteverted and horizontal pelvis (mean SS 49.3°, PT 9.7°) and posterior imbalance (mean SVA 5.8 cm). Postoperative measures showed significant impact of surgery with a PT reduction of 19° (p = 0.007), a mean SS increase of 15° (p = 0.04) and a LL gained of 10° (p = 0.2). Conclusion Sagittal spino-pelvic alignment in non-ambulating CP patients remains difficult to assess. The current literature is poor but our radiological study was able to define two distinct groups among Gross Motor Function Classification System (GMFCS) level V patients, based on the quality of their trunk control. All possible factors that may influence head and trunk posture should be systematically considered and optimized. Level of evidence Level IV

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Comparison of Sagittal Spinal Alignment on Standing Plain X-Rays and Supine MRI in Degenerative Lumbar Disease

10.21203/rs.3.rs-26627/v1 ◽

2020 ◽

Author(s):

Yulu Wang ◽

Jinwu Bai ◽

Zhijun Pan ◽

Deting Xue

Keyword(s):

Sagittal Alignment ◽

Correlation Coefficients ◽

Sacral Slope ◽

X Rays ◽

Degenerative Lumbar Diseases ◽

Angle Measurements ◽

Sagittal Spinal Alignment ◽

Spinal Sagittal Alignment ◽

Degenerative Lumbar Disease ◽

Magnetic Resonance Imaging Mri

Abstract Background:The purpose of present study is to examine the possible correlation between standing plain X-rays and supine MRI for evaluating spinal sagittal alignment in degenerative lumbar disease.Methods: The characteristics and images of 64 patients with degenerative lumbar diseases were reviewed retrospectively. The thoracolumbar junction kyphosis (TJK), lumbar lordosis (LL), and sacral slope (SS) were measured on lateral plain X-rays and by magnetic resonance imaging (MRI). Inter- and intra-observer reliability were tested using intra-class correlation coefficients. Results: The results suggested that TJK measurements obtained from MRI tended to underestimate the radiographic measures by 2°, whereas SS measurements obtained from MRI tended to overestimate the radiographic measures by 2°. The LL measurements obtained from MRI were approximately equal to the radiographic measures. The X-ray and MRI measurements were linearly related. Conclusions:In conclusion, supine MRI can be directly translated into sagittal alignment angle measurements obtained from standing X-rays with an acceptable degree of accuracy. This can avoid the impaired view caused by the overlapping ilium, while reducing the patient’s exposure to radiation.

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Increasing pelvic incidence is associated with more global sagittal imbalance in ankylosing spondylitis with thoracolumbar kyphosis

10.21203/rs.2.16543/v1 ◽

2019 ◽

Author(s):

Diyu Song ◽

Guoquan Zheng ◽

Tianhao Wang ◽

Dengbin Qi ◽

Yan Wang

Keyword(s):

Ankylosing Spondylitis ◽

Pelvic Incidence ◽

Vertical Axis ◽

Control Group ◽

Sacral Slope ◽

Sagittal Imbalance ◽

Thoracolumbar Kyphosis ◽

Spinopelvic Parameters ◽

Sagittal Vertical Axis ◽

The Relationship

Abstract Background: Ankylosing spondylitis (AS) patients with kyphosis have an abnormal spinopelvic alignment and pelvic morphology. Most of them focus on the relationship of pelvic tilt (PT) or sacral slope (SS) and deformity, and relatively few studies have addressed the relationship between pelvic incidence (PI) and kyphosis in AS patients. The purpose of this study is to analyze the correlation between pelvic incidence (PI) and the spinopelvic parameters describing local deformity or global sagittal balance in AS patients with thoracolumbar kyphosis. Methods: A total of 94 patients with AS (91 males and 3 females) and 30 controls were reviewed. Sagittal spinopelvic parameters, including PI, PT, SS, thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), lumbar lordosis(LL), sagittal vertical axis(SVA), T1 pelvic angle(TPA), spinosacral angle(SSA) and spinopelvic angle(SPA) were measured. Statistical analysis was performed to identify the correlation of PI with other parameters. Results: Compared with the control group, the AS patients had significantly higher PI(47.4˚ vs. 43.2˚, P<0.001). PI in AS patients was found to be significantly positively correlated with TPA(r=0.533, R 2 =0.284, P<0.001), and negatively correlated with SPA(r=-0.504, R 2 =0.254, P<0.001). However, no correlations were found between PI and SVA, SSA, TK, TLK or LL in AS patients. Conclusion: The value of PI in AS patients with kyphosis was significantly higher than that of controls. Correlation analysis revealed that increasing PI was significantly correlated with more global sagittal imbalance, not with the local deformity in AS patients with thoracolumbar kyphosis.

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Comparison of sagittal spinopelvic parameters in different types of double-level degenerative lumbar spondylolisthesis: a retrospective study

10.21203/rs.3.rs-30670/v1 ◽

2020 ◽

Author(s):

guangzhi zhang ◽

Yajun Deng ◽

Xuegang He ◽

Enhui Ren ◽

Zuolong Wu ◽

...

Keyword(s):

Back Pain ◽

Clinical Symptoms ◽

Leg Pain ◽

Neurogenic Claudication ◽

Sacral Slope ◽

Chronic Lower Back Pain ◽

Spinopelvic Parameters ◽

Lower Back ◽

Degenerative Lumbar Spondylolisthesis ◽

Different Types

Abstract Background Degenerative lumber spondylolisthesis (DLS), a common orthopaedic disease causing low back pain, seriously affects daily life and work. Although sagittal spinopelvic parameters have been studied in single-level DLS patients, investigations into different types of double-level DLS are scarce. This study aims to analyse the demographic and radiological parameters of patients with different types of double-level DLS and compare their differences to provide a reference for guiding surgical treatment and restoring sagittal balance of DLS patients. Methods From January 2014 to January 2020, double-level DLS patients’ records were retrospectively reviewed and divided into three types: anterior, posterior, and combined; the anterior and combined types were studied. Two spin surgeons measured the sagittal spinopelvic parameters: C7 tilt, maximal thoracic kyphosis (TKmax), maximal lumbar lordosis (LLmax), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). Following descriptive analysis, demographic and radiographic data were compared between the anterior and combined types. Results Patients in the anterior type group (n = 40) were older (67.68 ± 6.66 vs. 61.72 ± 10.06 years, P = 0.031), and the proportion of females were significantly higher (90% vs. 50%, P = 0.001) than the combined group (n = 18). Both groups had different levels of chronic lower back pain, but the incidence of radiating leg pain and neurogenic claudication was significantly higher in the anterior type. Owestry disability index and visual analogue scale lower back scores were also higher in the anterior type. In the anterior type, C7 tilt (7.14 ± 2.15 vs. 5.41 ± 2.28, P = 0.007), LLmax (50.02 ± 14.76 vs. 36.96 ± 14.56, P = 0.003), PI (68.28 ± 9.16 vs. 55.53 ± 14.19, P < 0.001), PT (28.68 ± 7.31 vs. 19.38 ± 4.70, P < 0.001), and PT/PI (42.45 ± 11.22 vs. 36.04 ± 9.87, P = 0.041) were significantly higher. In the anterior type, PI correlated significantly positively with LLmax (r = 0.59) and SS (r = 0.71). LLmax and SS (r = 0.65) had a positive correlation. PT/PI and SS (r = -0.77) had a negative correlation. In the combined type, PI correlated positively with LLmax (r = 0.61) and SS (r = 0.88), and PT/PI correlated negatively with SS (r = -0.81). Conclusions In patients with double-level DLS, the sagittal spinopelvic parameters differ between the anterior and combined types. PI and LLmax were significantly higher in the anterior type, resulting in compensation by forward flexion and pelvic retroversion. Spinal surgeons should focus on correcting sagittal deformities, relieving postoperative clinical symptoms, and improving quality of life during fusion surgery, which is proven to guarantee long-term surgical results.

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Effect of thoracic and pelvic anteroposterior diameters on spinal sagittal alignment

Journal of Orthopaedic Surgery ◽

10.1177/2309499019875539 ◽

2019 ◽

Vol 27 (3) ◽

pp. 230949901987553

Author(s):

Jeong Heo ◽

Woo-Kie Min ◽

Seung-Gi Min ◽

Kyung-Rok Kim

Keyword(s):

Multiple Regression ◽

Significant Relationship ◽

Sagittal Alignment ◽

Pearson Correlation ◽

Thoracic Inlet ◽

T1 Slope ◽

Anteroposterior Diameter ◽

Asymptomatic Patients ◽

Spinal Sagittal Alignment ◽

Global Sagittal Alignment

Purpose: This study aimed to analyze the effect of the thoracic anteroposterior diameter (TAPD) and pelvic anteroposterior diameter (PAPD) on global sagittal alignment in asymptomatic patients with normal sagittal alignment. Patient sample: The study investigated 2042 adult patients who initially presented at our hospital with a hip and knee problem without history of symptoms related to the entire spine. Only 57 patients with normal global sagittal alignment (C2–7 sagittal vertical axis (SVA) and C7–S1 SVA of <10 mm) were considered. Methods: The whole-spine standing lateral radiographs were obtained to analyze the following parameters: pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), thoracic inlet angle (TIA), T1 slope, cervical spinal parameters (angle of C0–2, C2–7, and C0–7), TAPD, and PAPD. Statistical analysis was performed using Pearson correlation coefficients and multiple regression analyses. Results: All the parameters showed a normal distribution. TAPD had a significant relationship with thoracic kyphosis (TK; r = 0.458), TIA ( r = 0.677), and C0–2 angle ( r = 0.294) but no significant relationship with T1 slope and other cervical parameters. PAPD had a significant relationship with PI ( r = 0.309) and PT ( r = 0.463) but no significant relationship with LL, SS, and TK. The multiple regression analysis showed that TIA = 21.974 + 0.405 (TK) + 0.188 (TAPD) ( p < 0.0001). Conclusions: TAPD and PAPD are associated with TIA, TK, C0–2 angle, PI, and PT, all of which act as key factors in spinal sagittal alignment. Although they did not directly correlate with other cervical parameters, T1 slope, and LL, TAPD and PAPD might have indirect effects on cervical and lumbar spinal sagittal alignment through their relationships with TIA, TK, and PI.

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