Progressive restoration of spinal sagittal balance after surgical correction of lumbosacral spondylolisthesis before skeletal maturity

OBJECT Spinopelvic alignment is crucial in assessing an energy-efficient posture in both normal and disease states, such as high-displacement developmental spondylolisthesis (HDDS). The overall effect in patients with HDDS who have undergone local surgical correction of lumbosacral imbalance for the global correction of spinal balance remains unclear. This paper reports the progressive spontaneous improvement of global sagittal balance following surgical correction of lumbosacral imbalance in patients with HDDS. METHODS The records of 15 patients with HDDS who underwent surgery between 2005 and 2010 were reviewed. The treatment consisted of L4–sacrum reduction and fusion via a posterior approach, resulting in complete correction of lumbosacral kyphosis. Preoperative, 6-month postoperative, and final follow-up postoperative angular measurements were taken from full-spine lateral radiographs obtained with the patient in a standard standing position. Radiographic measurements included pelvic incidence, sacral slope, lumbar lordosis, and thoracic kyphosis. The degree of lumbosacral kyphosis was evaluated by the lumbosacral angle. Because of the small number of patients, nonparametric tests were considered for data analysis. RESULTS Preoperative lumbosacral kyphosis and L-5 anterior slip were corrected by instrumentation. Transient neurological complications were noted in 5 patients. Statistical analysis showed a significant increase of thoracic kyphosis on 6-month postoperative and final follow-up radiographs (p < 0.001). A statistically significant decrease of lumbar lordosis was noted between preoperative and 6-month control radiographs (p < 0.001) and between preoperative and final follow-up radiographs (p < 0.001). CONCLUSIONS Based on the authors' observations, this technique resulted in an effective reduction of L-5 anterior slip and significant reduction of lumbosacral kyphosis (from 69.8° to 105.13°). Due to complete reduction of lumbosacral kyphosis and anterior trunk displacement associated with L-5 anterior slipping, lumbar lordosis progressively decreased and thoracic kyphosis progressively increased postoperatively. Adjusting the sagittal trunk balance produced not only pelvic anteversion, but also reciprocal adjustment of lumbar lordosis and thoracic kyphosis, creating a satisfactory level of compensated global sagittal balance.

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Can posterior stand-alone expandable cages safely restore lumbar lordosis? A minimum 5-year follow-up study

10.21203/rs.3.rs-27368/v3 ◽

2020 ◽

Author(s):

Seung-Kook Kim ◽

Ogeil Mubarak Elbashier ◽

Su-chan Lee ◽

Woo-jin Choi

Keyword(s):

Sagittal Balance ◽

Lumbar Lordosis ◽

Vertical Axis ◽

Control Group ◽

Sacral Slope ◽

Sagittal Vertical Axis ◽

Expandable Cage ◽

Cage Group

Abstract Background: Lumbar lordosis (LL) can be restored, and screw-related complications may be avoided with the stand-alone expandable cage method. However, the long-term spinopelvic changes and safety remain unknown. We aimed to elucidate the long-term radiologic outcomes and safety of this technique. Methods: Data from patients who underwent multi-level stand-alone expandable cage fusion and 80 patients who underwent screw-assisted fusion between February 2007 and December 2012, with at least 5 years of follow-up, were retrospectively analyzed. Segmental angle and translation, short and whole LL, pelvic incidence, pelvic tilt, sacral slope (SS), sagittal vertical axis, thoracic kyphosis, and presence of subsidence, pseudoarthrosis, retropulsion, cage breakage, proximal junctional kyphosis (PJK), and screw malposition were assessed. The relationship between local, lumbar, and spinopelvic effects was investigated. The implant failure rate was considered a measure of procedure effectiveness and safety. Results: In total, 69 cases were included in the stand-alone expandable cage group and 150 cases in the control group. The stand-alone group showed shorter operative time (58.48±11.10 versus 81.43±13.75, P=.00028), lower rate of PJK (10.1% versus 22.5%, P=.03), and restoration of local angle (4.66±3.76 versus 2.03±1.16, P=.000079) than the control group. However, sagittal balance (0.01±2.57 versus 0.50 ±2.10, P=.07) was not restored, and weakness showed higher rate of subsidence (16.31% versus 4.85 %, P=.0018), pseudoarthrosis (9.92% versus 2.42%, P=.02), cage, and retropulsion (3.55% versus 0, P=.01) than the control group.Conclusions: Stand-alone expandable cage fusion can restore local lordosis; however, global sagittal balance was not restored. Furthermore, implant safety has not yet been proven.

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Clinical and Short-Term Radiographic Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion With Expandable Lordotic Devices

Neurosurgery ◽

10.1093/neuros/nyz402 ◽

2019 ◽

Author(s):

Joseph H McMordie ◽

Kyle P Schmidt ◽

Andrew P Gard ◽

Christopher C Gillis

Keyword(s):

Minimally Invasive ◽

Lumbar Lordosis ◽

Interbody Fusion ◽

Pelvic Incidence ◽

Transforaminal Lumbar Interbody Fusion ◽

Sacral Slope ◽

Clinical Effects ◽

Lumbar Interbody Fusion ◽

Radiographic Measurements

Abstract BACKGROUND Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a well-accepted procedure for the treatment of degenerative lumbar disease. However, its ability to restore lumbar lordosis has been limited. Development of expandable lordotic interbody devices has challenged this limitation, furthering the scope of minimally invasive surgery. OBJECTIVE To evaluate the radiographic and clinical effects of expandable lordotic interbody devices placed through an MIS-TLIF approach. METHODS We conducted a retrospective review of 32 1-level and 18 2-level MIS-TLIFs performed using lordotic expandable interbody devices. Lumbar radiographic measurements, Oswestry Disability Index scores (ODI), and Visual Analogue Scale scores (VAS) were obtained at preoperative, 6 wk follow up, and last follow up time points. Last follow up occurred at a mean of 11.5 ± 7.6 mo (mean ± SD). RESULTS At 6-wk follow-up, segmental lordosis, disc height, and foraminal height increased by an average of 3.4°, 6.4 mm, and 4.4 mm, respectively. Only the 2-level group showed a significant increase in lumbar lordosis of 5.8°. No significant changes occurred in sacral slope, pelvic tilt, or pelvic incidence. Average ODI and VAS decreased by −12.0 and −4.5, respectively. Postoperative lumbar lordosis inversely correlated with preoperative lordosis in patients with an initial Pelvic Incidence to Lumbar Lordosis mismatch (PI-LL) of >10°, (r = −0.5, P = .009). CONCLUSION When applied across 2-levels, MIS-TLIF using expandable lordotic interbody devices produced a significant increase in lumbar lordosis. Preoperative lumbar lordosis was found to be a predictor of postoperative lumbar lordotic change in patients with sagittal imbalance.

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Changes in sagittal alignment after restoration of lower lumbar lordosis in patients with degenerative flat back syndrome

Journal of Neurosurgery Spine ◽

10.3171/spi-07/10/387 ◽

2007 ◽

Vol 7 (4) ◽

pp. 387-392 ◽

Cited By ~ 63

Author(s):

Jee-Soo Jang ◽

Sang-Ho Lee ◽

Jun-Hong Min ◽

Dae Hyeon Maeng

Keyword(s):

Lumbar Lordosis ◽

Thoracic Kyphosis ◽

Sagittal Alignment ◽

Plumb Line ◽

Sacral Slope ◽

Sagittal Imbalance ◽

Spontaneous Correction ◽

Flat Back ◽

Lower Lumbar

Object The authors investigate the correlation between thoracic and lumbar curves in patients with degenerative flat back syndrome, and demonstrate the predictability of spontaneous correction of the thoracic curve and sacral angle after surgical restoration of lower lumbar lordosis. Methods The cases of 28 patients treated with combined anterior and posterior spinal arthrodesis were retrospectively reviewed. Inclusion criteria included loss of lower lumbar lordosis resulting in sagittal imbalance. Total lumbar lordosis, thoracic kyphosis, sacral slope, and C-7 plumb line length were measured on pre- and postoperative lateral views of the whole spine. Postoperative changes in thoracic kyphosis, sacral slope, and length of the C-7 plumb line were measured and evaluated according to extent of lumbar lordosis restoration. Results The mean (± standard deviation) preoperative sagittal imbalance was 64.6 ± 63.2 mm, which improved to 15.8 ± 20.7 mm after surgery (p < 0.0001). The preoperative mean lumbar lordosis was 15.6 ± 14.1°, which increased to 40.3 ± 14.5° at follow-up (p < 0.0001). The preoperative mean thoracic kyphosis was 1.6 ± 10.5° and increased to 17.2 ± 12.5° at follow-up (p < 0.0001). Significant preoperative correlations existed between kyphosis and lordosis (r = 0.628, p = 0.0003), and between lordosis and sacral slope (r = 0.647, p = 0.0002). Postoperative correlations also existed between kyphosis and lordosis (r = 0.718, p < 0.0001 and r = 0.690, p < 0.0001, respectively). Conclusions Lower lumbar lordosis plays an important role in sagittal alignment and balance. Surgical restoration of lumbar lordosis results in predictable spontaneous correction of the thoracic curve and sacral slope in patients with degenerative flat back syndrome.

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Can posterior stand-alone expandable cages safely restore lumbar lordosis? A minimum 5-year follow-up study

Journal of Orthopaedic Surgery and Research ◽

10.1186/s13018-020-01866-5 ◽

2020 ◽

Vol 15 (1) ◽

Author(s):

Seung-Kook Kim ◽

Ogeil Mubarak Elbashier ◽

Su-chan Lee ◽

Woo-Jin Choi

Keyword(s):

Sagittal Balance ◽

Lumbar Lordosis ◽

Vertical Axis ◽

Control Group ◽

Sacral Slope ◽

Sagittal Vertical Axis ◽

Expandable Cage ◽

Cage Group

Abstract Background Lumbar lordosis (LL) can be restored, and screw-related complications may be avoided with the stand-alone expandable cage method. However, the long-term spinopelvic changes and safety remain unknown. We aimed to elucidate the long-term radiologic outcomes and safety of this technique. Methods Data from patients who underwent multi-level stand-alone expandable cage fusion and 80 patients who underwent screw-assisted fusion between February 2007 and December 2012, with at least 5 years of follow-up, were retrospectively analyzed. Segmental angle and translation, short and whole LL, pelvic incidence, pelvic tilt, sacral slope (SS), sagittal vertical axis, thoracic kyphosis, and presence of subsidence, pseudoarthrosis, retropulsion, cage breakage, proximal junctional kyphosis (PJK), and screw malposition were assessed. The relationship between local, lumbar, and spinopelvic effects was investigated. The implant failure rate was considered a measure of procedure effectiveness and safety. Results In total, 69 cases were included in the stand-alone expandable cage group and 150 cases in the control group. The stand-alone group showed shorter operative time (58.48 ± 11.10 vs 81.43 ± 13.75, P = .00028), lower rate of PJK (10.1% vs 22.5%, P = .03), and restoration of local angle (4.66 ± 3.76 vs 2.03 ± 1.16, P = .000079) than the control group. However, sagittal balance (0.01 ± 2.57 vs 0.50 ± 2.10, P = .07) was not restored, and weakness showed higher rate of subsidence (16.31% vs 4.85%, P = .0018), pseudoarthrosis (9.92% vs 2.42%, P = .02), cage, and retropulsion (3.55% vs 0, P = .01) than the control group. Conclusions Stand-alone expandable cage fusion can restore local lordosis; however, global sagittal balance was not restored. Furthermore, implant safety has not yet been proven.

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Adolescent idiopathic scoliosis: sagital plane and low density pedicle screws

Coluna/Columna ◽

10.1590/s1808-18512014130100210 ◽

2014 ◽

Vol 13 (1) ◽

pp. 13-15

Author(s):

Rodrigo Augusto do Amaral ◽

Robert Meves ◽

Maria Fernanda Silber Caffaro ◽

Ricardo Shigueaki Galhego Umeta ◽

Luciano Antônio Nassar Pelegrino ◽

...

Keyword(s):

Medical Records ◽

Lumbar Lordosis ◽

Thoracic Kyphosis ◽

Sagittal Plane ◽

Pedicle Screws ◽

Low Density ◽

Kyphosis Correction ◽

Pearson Coefficient ◽

Analysis Of Dispersion

OBJECTIVE: To examine the sagittal curves of patients treated with CD instrumentation using exclusively pedicle screws. METHODS: Image analysis of medical records of 27 patients (26 M and 1 F) with a minimum follow-up of 6 months, who underwent surgical treatment in our service between January 2005 and December 2010. The curves were evaluated on coronal and sagittal planes, taking into account the potential correction of the technique. RESULTS: In the coronal plan the following curves were evaluated: proximal thoracic (TPx), main thoracic (TPp), and thoracolumbar; lumbar (TL, L), and the average flexibility was 52%, 52%, and 92% and the capacity of correction was 51%, 72%, and 64%, respectively. In the sagittal plane there was a mean increase in thoracic kyphosis (CT) of 41% and an average reduction of lumbar lordosis (LL) of 17%. Correlation analysis between variables showed Pearson coefficient of correlation of 0.053 and analysis of dispersion of R2 = <0.001. CONCLUSION: The method has shown satisfactory results with maintenance of kyphosis correction in patients with normal and hyper kyphotic deformities.

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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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Posterior-Only Approach with Pedicle Screws for the Correction of Scheuermann's Kyphosis

Asian Spine Journal ◽

10.4184/asj.2017.11.4.513 ◽

2017 ◽

Vol 11 (4) ◽

pp. 513-519 ◽

Cited By ~ 1

Author(s):

Adem Cobden ◽

Akif Albayrak ◽

Yalkin Camurcu ◽

Hakan Sofu ◽

Temel Tacal ◽

...

Keyword(s):

Lumbar Lordosis ◽

Thoracic Kyphosis ◽

Pedicle Screws ◽

Definitive Treatment ◽

Sacral Slope ◽

Complication Rates ◽

Level Of Evidence ◽

Radiological Results ◽

Lower Complication ◽

Clinical And Radiological Results

<sec><title>Study Design</title>Retrospective study (level of evidence: level 3).</sec><sec><title>Purpose</title>The purpose of this study was to evaluate the clinical and radiological results of the posterior-only approach with pedicle screws for the treatment of Scheuermann's kyphosis (SK).</sec><sec><title>Overview of Literature</title>The correction of SK with instrumentation can be performed using posterior-only or combined anterior-posterior procedures. With the use of all-pedicle screw constructs in spine surgery, the posterior-only approach has become a popular option for the definitive treatment of SK. In a nationwide study involving 2,796 patients, a trend toward posterior-only fusion with lower complication rates was reported.</sec><sec><title>Methods</title>We retrospectively reviewed the data of patients who underwent posterior-only correction for SK between January 2005 and May 2013. Patients with a definite diagnosis of SK who fulfilled the minimum follow-up criterion of 24 months were included. The thoracic kyphosis (T5–T12), lumbar lordosis (L1–S1), and thoracolumbar junction (T10–L2) angles were measured from preoperative, postoperative, and last control radiographs. Sagittal balance, thoracic length, thoracic diameter, Voutsinas index and the sacral slope, pelvic tilt, proximal junction kyphosis, and distal junction kyphosis angles were also measured.</sec><sec><title>Results</title>Forty-five patients underwent surgery for the treatment of SK between 2005 and 2013. After applying the exclusion criteria, 20 patients (18 males and 2 females) with a mean age of 19 years were included. The mean thoracic kyphosis angle was 79.8 degrees preoperatively, 44.6 degrees postoperatively, and 44.9 degrees at the last control. There were statistically significant differences between preoperative and postoperative values in the thoracic kyphosis and lumbar lordosis angles, thoracic length, thoracic diameter, and Voutsinas index (<italic>p</italic><0.05).</sec><sec><title>Conclusions</title>The clinical and radiological results of the current study suggest that posterior-only fusion is an efficient technique for the treatment of SK.</sec>

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Can posterior stand-alone expandable cages safely restore lumbar lordosis? A minimum 5-year follow-up study

10.21203/rs.3.rs-27368/v1 ◽

2020 ◽

Author(s):

Seung-Kook Kim ◽

Ogeil Mubarak Elbashier ◽

Su-chan Lee ◽

Woo-jin Choi

Keyword(s):

Lumbar Lordosis ◽

Control Group ◽

Sacral Slope ◽

Expandable Cage ◽

Profile Changes ◽

The Relationship ◽

Screw Malposition ◽

Segmental Angle

Abstract Background Lumbar lordosis (LL) can be restored and screw-related complications may be avoided with the stand-alone expandable cage method. However, the long-term spinopelvic profile changes and safety remain unknown. We aimed to elucidate the long-term radiologic outcomes and safety of this technique. Methods Data from a total of 69 patients who underwent multi-level stand-alone expandable cage fusion and 80 patients who underwent screw-assisted fusion between February 2007 and December 2012, with at least 5 years of follow-up, were retrospectively analyzed. Segmental angle and translation, short and whole LL, pelvic incidence, pelvic tilt, sacral slope (SS), sagittal vertical balance, thoracic kyphosis, and presence of subsidence, pseudoarthrosis, retropulsion, cage breakage, proximal junctional kyphosis (PJK), and screw malposition were assessed. The relationship between local and spinopelvic effects was investigated. The implant failure rate was considered a measure of procedure effectiveness and safety. Results The stand-alone expandable cage fusion group showed shorter operative times, a lower rate of PJK, and better improvements in segmental angles than the control group, and there was a positive correlation with LL. However, the whole LL was not restored; the SS significantly increased; and subsidence, pseudoarthrosis, and retropulsion rates were significantly higher than those in the control group. Conclusions Stand-alone expandable cage fusion can restore local lordosis, however, global sagittal balance was not restored. Furthermore, implant safety still has not been proven.

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The Impact of Spinopelvic Mobility on Arthroplasty: Implications for Hip and Spine Surgeons

Journal of Clinical Medicine ◽

10.3390/jcm9082569 ◽

2020 ◽

Vol 9 (8) ◽

pp. 2569 ◽

Cited By ~ 1

Author(s):

Henryk Haffer ◽

Dominik Adl Amini ◽

Carsten Perka ◽

Matthias Pumberger

Keyword(s):

Lumbar Lordosis ◽

Flexion Contracture ◽

Sacral Slope ◽

Eos Imaging ◽

Appropriate Treatment ◽

Number Of Patients ◽

Increased Risk ◽

Sagittal Spinal Balance ◽

Hip Flexion ◽

The Impact

Spinopelvic mobility represents the complex interaction of hip, pelvis, and spine. Understanding this interaction is relevant for both arthroplasty and spine surgeons, as a predicted increasing number of patients will suffer from hip and spinal pathologies simultaneously. We conducted a comprehensive literature review, defined the nomenclature, summarized the various classifications of spinopelvic mobility, and outlined the corresponding treatment algorithms. In addition, we developed a step-by-step workup for spinopelvic mobility and total hip arthroplasty (THA). Normal spinopelvic mobility changes from standing to sitting; the hip flexes, and the posterior pelvic tilt increases with a concomitant increase in acetabular anteversion and decreasing lumbar lordosis. Most classifications are based on a division of spinopelvic mobility based on ΔSS (sacral slope) into stiff, normal, and hypermobile, and a categorization of the sagittal spinal balance regarding pelvic incidence (PI) and lumbar lordosis (LL) mismatch (PI–LL = ± 10° balanced versus PI–LL > 10° unbalanced) and corresponding adjustment of the acetabular component implantation. When performing THA, patients with suspected pathologic spinopelvic mobility should be identified by medical history and examination, and a radiological evaluation (a.p. pelvis standing and lateral femur to L1 or C7 (if EOS (EOS imaging, Paris, France) is available), respectively, for standing and sitting radiographs) of spinopelvic parameters should be conducted in order to classify the patient and determine the appropriate treatment strategy. Spine surgeons, before planned spinal fusion in the presence of osteoarthritis of the hip, should consider a hip flexion contracture and inform the patient of an increased risk of complications with existing or planned THA.

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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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