scholarly journals Conflicting calculations of pelvic incidence and pelvic tilt secondary to transitional lumbosacral anatomy (lumbarization of S-1): case report

2017 ◽  
Vol 26 (1) ◽  
pp. 45-49 ◽  
Author(s):  
Charles H. Crawford ◽  
Steven D. Glassman ◽  
Jeffrey L. Gum ◽  
Leah Y. Carreon
Keyword(s):  
Sagittal Balance ◽  
Lumbar Lordosis ◽  
Pelvic Incidence ◽  
Adult Spinal Deformity ◽  
Accurate Identification ◽  
Current Case ◽  
Pelvic Parameters ◽  
Radiology Reports ◽  
Sagittal Malalignment

Advancements in the understanding of adult spinal deformity have led to a greater awareness of the role of the pelvis in maintaining sagittal balance and alignment. Pelvic incidence has emerged as a key radiographic measure and should closely match lumbar lordosis. As proper measurement of the pelvic incidence requires accurate identification of the S-1 endplate, lumbosacral transitional anatomy may lead to errors. The purpose of this study is to demonstrate how lumbosacral transitional anatomy may lead to errors in the measurement of pelvic parameters. The current case highlights one of the potential complications that can be avoided with awareness. The authors report the case of a 61-year-old man who had undergone prior lumbar surgeries and then presented with symptomatic lumbar stenosis and sagittal malalignment. Radiographs showed a lumbarized S-1. Prior numbering of the segments in previous surgical and radiology reports led to a pelvic incidence calculation of 61°. Corrected numbering of the segments using the lumbarized S-1 endplate led to a pelvic incidence calculation of 48°. Without recognition of the lumbosacral anatomy, overcorrection of the lumbar lordosis might have led to negative sagittal balance and the propensity to develop proximal junction failure. This case illustrates that improper identification of lumbosacral transitional anatomy may lead to errors that could affect clinical outcome. Awareness of this potential error may help improve patient outcomes.

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

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.

Implications of Spinopelvic Alignment for the Spine Surgeon

Neurosurgery ◽  
2011 ◽  
Vol 70 (3) ◽  
pp. 707-721 ◽  
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.

Implications of Spinopelvic Alignment for the Spine Surgeon

Neurosurgery ◽  
2011 ◽  
Vol 76 (suppl_1) ◽  
pp. S42-S56 ◽  
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.

scholarly journals Acute Reciprocal Changes Distant from the Site of Spinal Osteotomies Affect Global Postoperative Alignment

2011 ◽  
Vol 2011 ◽  
pp. 1-7 ◽  
Author(s):  
Eric Klineberg ◽  
Frank Schwab ◽  
Christopher Ames ◽  
Richard Hostin ◽  
Shay Bess ◽  
...  
Keyword(s):  
Lumbar Lordosis ◽  
Thoracic Kyphosis ◽  
Radiographic Analysis ◽  
Pelvic Parameters ◽  
Sagittal Malalignment ◽  
Lumbar Osteotomy

Introduction. Three-column vertebral resections are frequently applied to correct sagittal malalignment; their effects on distant unfused levels need to be understood.Methods. 134 consecutive adult PSO patients were included (29 thoracic, 105 lumbar). Radiographic analysis included pre- and postoperative regional curvatures and pelvic parameters, with paired independentt-tests to evaluate changes.Results. A thoracic osteotomy with limited fusion leads to a correction of the kyphosis and to a spontaneous decrease of the unfused lumbar lordosis (−8°). When the fusion was extended, the lumbar lordosis increased (+8°). A lumbar osteotomy with limited fusion leads to a correction of the lumbar lordosis and to a spontaneous increase of the unfused thoracic kyphosis (+13°). When the fusion was extended, the thoracic kyphosis increased by 6°.Conclusion. Data from this study suggest that lumbar and thoracic resection leads to reciprocal changes in unfused segments and requires consideration beyond focal corrections.

scholarly journals Beyond Pelvic Incidence–Lumbar Lordosis Mismatch: The Importance of Assessing the Entire Spine to Achieve Global Sagittal Alignment

2017 ◽  
Vol 7 (6) ◽  
pp. 536-542 ◽  
Author(s):  
Robert K. Merrill ◽  
Jun S. Kim ◽  
Dante M. Leven ◽  
Joung Heon Kim ◽  
Samuel K. Cho
Keyword(s):  
Lumbar Lordosis ◽  
Pelvic Incidence ◽  
Adult Spinal Deformity ◽  
Case Series ◽  
Vertical Axis ◽  
Retrospective Case ◽  
Sagittal Vertical Axis ◽  
Global Sagittal Alignment ◽  
Sagittal Parameters ◽  
Combined Parameters

Study Design: Retrospective case series. Objective: To investigate which sagittal parameters contribute to a normal sagittal vertical axis (SVA) when there is a pelvic incidence-lumbar lordosis (PI-LL) mismatch >10° following adult spinal deformity (ASD) correction. Methods: We performed a retrospective review of ASD patients with >5 levels fused. Sagittal measurements between cohorts of postoperative PI-LL >10° and PI-LL<10° were compared. We correlated SVA to pelvic tilt (PT), thoracic kyphosis (TK), PI-LL, cervical lordosis (CL), and correlated the pre- to postoperative change in SVA to change in PT, change in TK, change in PI-LL, and change in CL. We also correlated SVA and the change in SVA to combined parameters of ((PI-LL) − PT + TK). Results: We analyzed 52 patients with a mean age of 59 ± 16 years. In patients with a postoperative SVA <5cm, a smaller TK was seen when PI-LL >10° than when PI-LL<10° (15.45° vs 33.04°, P = .0004). Additionally, PT was larger when PI-LL >10° than when PI-LL <10° (25.73° vs 19.07°, P = .006). SVA correlated better with ((PI-LL) − PT + TK) ( R2 = 0.51) than with PI-LL alone ( R2 = 0.33). Lastly, there was no significant correlation between change in pre- to postoperative SVA with change in TK for all cases ( P = .73), but in cases where change in PI-LL was <10°, there was a significant correlation between change in TK and change in SVA ( P = .009). Conclusion: Our results demonstrate that PT and TK, and not just PI-LL, play an important role in maintaining sagittal balance when there is a PI-LL mismatch >10°.

scholarly journals Minimally invasive transforaminal lumbar interbody fusion with expandable versus static interbody devices: radiographic assessment of sagittal segmental and pelvic parameters

2017 ◽  
Vol 43 (2) ◽  
pp. E10 ◽  
Author(s):  
Ammar H. Hawasli ◽  
Jawad M. Khalifeh ◽  
Ajay Chatrath ◽  
Chester K. Yarbrough ◽  
Wilson Z. Ray
Keyword(s):  
Lumbar Lordosis ◽  
Pelvic Incidence ◽  
Transforaminal Lumbar Interbody Fusion ◽  
Disc Height ◽  
Disc Space ◽  
Pelvic Parameters ◽  
Radiographic Measurements ◽  
Index Level ◽  
Segmental Lordosis ◽  
Foraminal Height

OBJECTIVEMinimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has been adopted as an alternative technique to hasten recovery and minimize postoperative morbidity. Advances in instrumentation technologies and operative techniques have evolved to maximize patient outcomes as well as radiographic results. The development of expandable interbody devices allows a surgeon to perform MIS-TLIF with minimal tissue disruption. However, sagittal segmental and pelvic radiographic outcomes after MIS-TLIF with expandable interbody devices are not well characterized. The object of this study is to evaluate the radiographic sagittal lumbar segmental and pelvic parameter outcomes of MIS-TLIF performed using an expandable interbody device.METHODSA retrospective review of MIS-TLIFs performed between 2014 and 2016 at a high-volume center was performed. Radiographic measurements were performed on lateral radiographs before and after MIS-TLIF with static or expandable interbody devices. Radiographic measurements included disc height, foraminal height, fused disc angle, lumbar lordosis, pelvic incidence, sacral slope, and pelvic tilt. Mismatch between pelvic incidence and lumbar lordosis were calculated for each radiograph.RESULTSA total of 48 MIS-TLIFs were performed, predominantly at the L4–5 level, in 44 patients. MIS-TLIF with an expandable interbody device led to a greater and more sustained increase in disc height when compared with static interbody devices. Foraminal height increased after MIS-TLIF with expandable but not with static interbody devices. MIS-TLIF with expandable interbody devices increased index-level segmental lordosis more than with static interbody devices. The increase in segmental lordosis was sustained in the patients with expandable interbody devices but not in patients with static interbody devices. For patients with a collapsed disc space, MIS-TLIF with an expandable interbody device provided superior and longer-lasting increases in disc height, foraminal height, and index-level segmental lordosis than in comparison with patients with static interbody devices. Using an expandable interbody device improved the Oswestry Disability Index scores more than using a static interbody device, and both disc height and segmental lordosis were correlated with improved clinical outcome. Lumbar MIS-TLIF with expandable or static interbody devices had no effect on overall lumbar lordosis, pelvic parameters, or pelvic incidence–lumbar lordosis mismatch.CONCLUSIONSPerforming MIS-TLIF with an expandable interbody device led to a greater and longer-lasting restoration of disc height, foraminal height, and index-level segmental lordosis than MIS-TLIF with a static interbody device, especially for patients with a collapsed disc space. However, neither technique had any effect on radiographic pelvic parameters.

scholarly journals Improvement of sagittal balance and lumbar lordosis following less invasive adult spinal deformity surgery with expandable cages and percutaneous instrumentation

2013 ◽  
Vol 18 (1) ◽  
pp. 4-12 ◽  
Author(s):  
Michael Y. Wang
Keyword(s):  
Minimally Invasive Surgery ◽  
Minimally Invasive ◽  
Invasive Surgery ◽  
Spinal Deformity ◽  
Sagittal Balance ◽  
Lumbar Lordosis ◽  
Adult Spinal Deformity ◽  
Surgical Methods ◽  
The Mean ◽  
Expandable Cages

Object The treatment of adult spinal deformity (ASD) remains a challenge for the spine surgeon. While minimally invasive surgery (MIS) has many favorable attributes that would be of great benefit for the ASD population, improvements in lordosis and sagittal balance have remained elusive in cases involving the MIS approach. This report describes the evolution of an MIS method for treating ASD with attention to sagittal correction. Methods Over an 18-month period 25 patients with thoracolumbar scoliosis were treated surgically. The mean patient age was 72 years, and 68% of the population was female. Patients were treated with multilevel facet osteotomies and interbody fusion in which expandable cages (mean 3.2 levels) were placed and percutaneous screw fixation (mean 5.3 levels) was performed. Seven patients underwent supplemental percutaneous iliac fixation. Results All patients underwent MIS without conversion to a traditional open procedure. The mean operative time was 273 mins and the mean blood loss was 416 ml. There were no intraoperative complications. The Cobb angle over the scoliotic deformity improved from a mean of 29.2° to that of 9.0° (p < 0.001). Lumbar lordosis between L-1 and S-1 improved from a mean of 27.8° to one of 42.6° (p < 0.001). Sagittal vertical axis improved from 7.4 cm to 4.3 cm (p = 0.001). Numeric pain scale scores improved as well, an average of 3.3 and 4.2 for the leg and back, respectively. A mean improvement of 20.8 points on the Oswestry Disability Index was seen at 12 months. Complications included: two cases requiring hardware repositioning, one case of screw pullout, one asymptomatic pedicle screw breach, prolonged hospitalization from constipation, and one acute coronary syndrome developing 3 days after surgery without myocardial damage. Conclusions An expanding body of evidence suggests that sagittal balance remains a keystone for good outcomes after ASD surgery. Minimally invasive surgery that involves a combination of osteotomies, interbody height restoration, and advanced fixation techniques may achieve this goal in patients with less severe deformities. While feasibility will have to be proven with larger series and improved surgical methods, the present technique holds promise as a means of reducing the significant morbidity associated with surgery in the ASD population.

scholarly journals The Clinical Significance of L5 Incidence in Patients with High Pelvic Incidence: A Case Report

2019 ◽  
pp. 1-4
Author(s):  
Ippei Yamauchi
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Lumbar Lordosis ◽  
Pelvic Incidence ◽  
Low Back ◽  
Background Data ◽  
Distribution Index ◽  
Severe Difficulty ◽  
Sagittal Malalignment ◽  
Whole Spine

Objective: To present a case of sagittal malalignment with high pelvic incidence and its surgical management. Summary of Background Data: Though rare, patients with high pelvic incidence (PI) around 90° without spondylolisthesis or spondylolysis often show sagittal malalignment with low back pain. However, little has been reported about the treatment of such cases. Methods: We report a case of a 15-year-old female complaining of severe difficulty in maintaining an upright position and gait disturbance due to back pain. Radiographs showed high PI of 88° and L5 incidence (L5I) of 67° combined with hyperlordosis of lumbar segments. A lower Lordosis Distribution Index (LDI; percentage of lordosis on segments L4–S1 in entire lumbar lordosis of L1-S1) was detected despite the high overall lumbar lordosis. The patient was surgically treated by two-stage combined posterior and anterior short fusion from the sacrum. Results: The surgical strategy was planned with attention to L5I instead of PI. L5I decreased to 49° and sagittal alignment of the whole spine—including cervical, thoracic, and lumbar spine—improved without any complications. Activity of daily living (ADL）improved preoperatively with relief of low back pain. Conclusions: Improvement of L5I by performing short fusion from L4 to S1 may be a strategy for patients with high PI complaining of low back pain due to sagittal malalignment.

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