Two different types of postoperative sagittal imbalance after long instrumented fusion to the sacrum for degenerative sagittal imbalance

2020 ◽  
Vol 33 (5) ◽  
pp. 613-622
Author(s):  
Hyung-Youl Park ◽  
Young-Hoon Kim ◽  
Sang-Il Kim ◽  
Sung-Bin Han ◽  
Kee-Yong Ha
Keyword(s):  
Risk Factors ◽  
Sagittal Alignment ◽  
Sacral Slope ◽  
Sagittal Imbalance ◽  
Instrumented Fusion ◽  
Radiographic Measurements ◽  
Paravertebral Muscles ◽  
Different Types ◽  
Fatty Atrophy ◽  
Whole Spine

OBJECTIVEFew studies have addressed that dynamic sagittal imbalance can develop distal to the spinal fusion and cause sagittal malalignment, unlike proximal junctional kyphosis (PJK) in the proximal portion. The purpose of this study was to investigate risk factors between the 2 different types of postoperative sagittal imbalance after long fusion to the sacrum for the treatment of degenerative sagittal imbalance (DSI).METHODSEighty patients who had undergone surgical correction for DSI were included. Radiographic measurements included spinopelvic parameters on whole-spine plain radiographs and degeneration of paravertebral muscles on MRI. Univariate and multivariate analyses for clinical and radiological factors were conducted for respective risk factors. In subgroup analyses, the 2 different types of postoperative sagittal imbalance were directly compared.RESULTSForty patients (50%) developed postoperative sagittal imbalance; of these patients, 22 (55.0%) developed static proximal kyphosis from PJK, and 18 patients (45.0%) developed dynamic sagittal imbalance without PJK. The independent risk factors in proximal kyphosis were greater postoperative pelvic tilt (HR 1.11) and less change in sacral slope (SS) (HR 1.09), whereas there were more fusion levels (HR 3.11), less change in SS (HR 1.28), and less change in thoracic kyphosis (HR 1.26) in dynamic sagittal imbalance. Directly compared with the proximal kyphosis group, dynamic sagittal imbalance was more commonly found in patients who had less correction of sagittal parameters as well as fatty atrophy of the paravertebral muscles. Clinical outcomes in the dynamic sagittal imbalance group were superior to those in the proximal kyphosis group.CONCLUSIONSOptimal correction of sagittal alignment should be considered in long instrumented fusion for DSI, because insufficient correction might cause one of 2 different types of postoperative sagittal imbalance at different sites of decompression. Dynamic sagittal imbalance compared with proximal kyphosis was significantly associated with less correction of sagittal alignment, in conjunction with more fusion levels and degeneration of the paravertebral muscles.

scholarly journals Novel Method for Evaluation of Sagittal Spinal Alignment Using Cluster Analysis of Slope of Each Vertebra.

2021 ◽  
Author(s):  
Yoshitaka Matsubayashi ◽  
Yasushi Oshima ◽  
Yuki Taniguchi ◽  
Toru Doi ◽  
So Kato ◽  
...  
Keyword(s):  
Cluster Analysis ◽  
Sagittal Alignment ◽  
Thoracolumbar Junction ◽  
Sacral Slope ◽  
Spinal Alignment ◽  
Sagittal Spinal Alignment ◽  
Significant Difference ◽  
Novel Method ◽  
And Cluster Analysis ◽  
Whole Spine

Abstract Background: The parameters of sagittal spinal alignment proposed to date measure only the specific sectional angle or the specific sectional distance of the entire spine. To evaluate the alignment of the entire spine without segmentation, we sought to measure and analyze the slope of each vertebral body from skull to pelvis. The purpose of this study was to confirm the effectiveness of this novel analytic method for the evaluation of spinal alignment that considers the slope of each spinal vertebra using graph and cluster analysis.Methods: Every spinal slope from McGregor’s slope to the sacral slope of 88 patients who underwent standing whole spine radiography was measured. Subsequently, we conducted cluster analysis of each spinal slope to understand the characteristics of sagittal alignment.Results: Cluster analysis of whole spinal slopes did not provide useful results in this study because the number of cases per cluster was small due to the large number of parameters. Therefore, we focused the cluster analysis on only the cervical spine slopes. Then, we categorized cervical alignment into four groups (named Normal, Mismatch, Straight, and Sigmoid) based on the results of the cluster analysis. Patients in the Normal and Mismatch groups were older and had lower lumbar apex (L4), apparent lordo-kyphosis around the thoracolumbar junction, and high thoracic kyphosis (TK). Patients in the straight and sigmoid groups were younger, had a higher lumbar apex (L3), flat thoracolumbar junction, and low TK. There was no significant difference between the four groups with respect to pelvic incidence (PI) or pelvic tilt (PT).Conclusion: We proposed a novel method for visually understanding sagittal alignment. Using this analysis method, differences and similarities of sagittal alignment between each group can be easily identified. More detailed analysis of the whole spine may be possible by increasing the number of cases.

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

2018 ◽  
Vol 79 (06) ◽  
pp. 479-485
Author(s):  
Sho Dohzono ◽  
Yusuke Hori ◽  
Shinji Takahashi ◽  
Akinobu Suzuki ◽  
Hidetomi Terai ◽  
...  
Keyword(s):  
Sagittal Alignment ◽  
Degenerative Spondylolisthesis ◽  
Group Versus ◽  
Leg Pain ◽  
Sacral Slope ◽  
Sagittal Imbalance ◽  
Low Grade ◽  
Spinopelvic Parameters ◽  
Spinal Sagittal Alignment ◽  
Global Sagittal Alignment

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.

scholarly journals Effect of cervical flexion and extension on thoracic sagittal alignment

2019 ◽  
Vol 27 (3) ◽  
pp. 230949901987699 ◽  
Author(s):  
Takamitsu Konishi ◽  
Kenji Endo ◽  
Takato Aihara ◽  
Yuji Matsuoka ◽  
Hidekazu Suzuki ◽  
...  
Keyword(s):  
Spinal Surgery ◽  
Thoracic Kyphosis ◽  
Pelvic Tilt ◽  
Sagittal Alignment ◽  
Sacral Slope ◽  
Corrective Surgery ◽  
Axial Angle ◽  
History Of ◽  
Whole Spine ◽  
Flexion And Extension

Introduction: The cervical spine has the largest sagittal motion in the whole spine, and cervical alignment affects the thoracic sagittal alignment. However, the effects of cervical flexion and extension on thoracic sagittal alignment have not been investigated in detail. The purpose of this study was to analyze the change of thoracic sagittal alignment following cervical flexion and extension. Subjects and methods: A total of 55 consecutive patients (42 men and 13 women; average age 49.1 years) who presented to our department with spinal degenerative disease between January 2016 and September 2017 were enrolled in our study. Subjects with a history of trauma, infection, tumor, inflammatory disease, ossification, or cervical deformities, and those who had undergone spinal surgery were excluded. The following parameters were analyzed: occipito-axial angle (O–C2), C2 slope (C2S), C2–C7 angle, T1 slope (T1S), thoracic kyphosis, T1–T4 angle, T5–T8 angle, T9–T12 angle, lumbar lordosis, sacral slope, pelvic tilt in cervical flexion, neutral, and extension. Results: Cervical flexion significantly decreased O–C2, C2–C7 angles and T1S, and increased C2S. Cervical extension conversely changed these parameters. At cervical flexion, the correlation of C2–C7 angle with thoracic parameters was maintained, except for the T1–T4 angle. At cervical extension, the correlation was observed with T1S and T1–T4 angle. Conclusion: Cervical flexion affects the T1S and T5–T8 angle, but there is no significant change in T1–T4 and T9 and lower spino-pelvic columns. This study suggests that T2–T4 can be considered as a stable distal end when cervical long fixation for corrective surgery is performed.

scholarly journals Diagnosis, Risk Factors, and Management of Sacral and Pelvic Fractures After Instrumented Lumbar Fusions: A Systematic Review

2018 ◽  
Vol 9 (5) ◽  
pp. 540-544
Author(s):  
Andrei F. Joaquim ◽  
Alpesh A. Patel
Keyword(s):  
Risk Factors ◽  
Systematic Review ◽  
Pelvic Fractures ◽  
Sagittal Imbalance ◽  
Level Of Evidence ◽  
Instrumented Fusion ◽  
Diagnosis And Management ◽  
Pubmed Database ◽  
Iliac Screws ◽  
Nondisplaced Fracture

Study Design: Systematic literature review. Objectives: To evaluate risk factors, diagnosis, and management of sacral and pelvic fractures (SPFs) after instrumented fusions. Methods: A systematic review following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed using the PubMed database. Articles with patients with an SPF after a lumbar instrumented fusion were included. The articles addressing specifically proximal junctional kyphosis were excluded. Eleven small cases series (level of evidence IV) were reviewed. Results: The incidence of SPF was 1.86% in one study. The risk factors reported were elderly patients, multilevel surgery, long fusions stopping at L5 or S1 instead of the ilium, osteoporosis, obesity, and sagittal imbalance. Computed tomography scan was the preferential image modality for diagnosing. Nonsurgical treatment may be used in patients with tolerable pain and nondisplaced fracture. Persistent pain was an indication for surgery, as well as fracture displacement. The most common surgical treatment reported was an extension of the fusion to the iliac using iliac screws. Conclusion: SPFs after lumbar instrumented fusion are rare but clinically meaningful complications. The risk factors, diagnosis, and management of SPFs are described in our review.

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

2007 ◽  
Vol 7 (4) ◽  
pp. 387-392 ◽  
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.

Demands on Posterior Fusion Hardware During Lordosis Restoration Procedures

2013 ◽  
Author(s):  
Audrey Martin ◽  
Connor Telles ◽  
Jeremi Leasure ◽  
Jessica Tang ◽  
Christopher Ames ◽  
...  
Keyword(s):  
Lumbar Lordosis ◽  
Sagittal Alignment ◽  
Critical Role ◽  
Biomechanical Study ◽  
Posterior Fusion ◽  
Sacral Slope ◽  
Sagittal Imbalance ◽  
Comparative Performance ◽  
Lower Lumbar

Lower lumbar lordosis plays a critical role in sagittal alignment. It has been shown that restoration of lumbar lordosis in patients with preoperative sagittal imbalance is necessary to prevent postoperative sagittal decompensation [1]. Further, restoration of lower lumbar lordosis in patients with degenerative flatback syndrome has been shown clinically to result in additional correction of the thoracic curve and sacral slope [2]. Currently, there are three commonly used intraoperative techniques to restore lumbar lordosis: (1) cantilever bending, (2) in situ bending, and (3) compression and/or distraction of screws along posterior fusion rods. Although powerful, all three techniques require the surgeon to impart large forces to the accompanying posterior fusion hardware, often causing failure of hardware and inconsistency to achieve pre-operatively planned lordosis. To date, there has been no clinical or biomechanical study to address the comparative performance of these three techniques. In efforts to determine a standard of care for sagittal alignment via lumbar lordosis restoration, the goal of this study is to establish a relation between the three techniques, and the resulting demands on posterior fusion hardware. It is hypothesized that greater loads will be observed in the hardware during in situ bending, increasing the risk of pedicle screw pullout.

Incidence and Risk Factors for L5-S1 Complications After Long-level Floating Fusion in Adult Degenerative Scoliosis

2021 ◽  
Author(s):  
Tinghua Jiang ◽  
Yunzhong Cheng ◽  
Yong Hai ◽  
Xinuo Zhang ◽  
Qingjun Su ◽  
...  
Keyword(s):  
Risk Factors ◽  
Sacral Slope ◽  
Multivariate Logistic Regression ◽  
Degenerative Scoliosis ◽  
Instrumented Fusion ◽  
Adult Degenerative Scoliosis ◽  
Related Risk ◽  
Potential Risk Factors ◽  
Independent Risk Factors

Abstract Background Whether to preserve L5-S1 with no pre-existing pathology in the fusion for patients with adult degenerative scoliosis (ADS) remains controversial. This study is to determine the predictors of L5-S1 diseases for the distal fusion to L5 in the long instrumented fusion for ADS. Methods A total of 159 patients with ADS who had undergone long floating fusion were evaluated with a minimum 2 year follow-up between 2014 to 2018. The patient- and surgical-related risk factors for each individual were identified by using univariate testing. All patients were divided into groups with and without L5-S1 diseases. Univariate testing was used to identify the potential risk factors. Independent risk factors of L5-S1 diseases were identified using multivariate logistic regression. Results BMD of the patients with L5-S1 diseases were much higher than that without L5-S1 diseases (P = 0.003). Postoperative sacral slope in L5-S1 diseases group was much higher than that without L5-S1 diseases group (P = 0.000). Patient-related independent risk factors for the development of L5-S1 diseases included gender (OR = 0.41, P = 0.016) and BMD (OR = 0.42, P = 0.000). Surgical-related independent risk factors for the development of L5-S1 diseases included fusion level (OR = 2.64, P = 0.033) and postoperative sacral slope (OR = 1.43, P = 0.000).ConclusionsGender and BMD were the most common patient-related independent risk factors, Fusion levels and postoperative sacral slope were the most common surgical-related independent risk factors. Prevention of these risk factors can reduce the incidence of L5-S1 diseases in patients with long floating fusion.

Graft detachments in endothelial keratoplasty

2021 ◽  
pp. bjophthalmol-2020-318092
Author(s):  
Rashmi Deshmukh ◽  
Sridevi Nair ◽  
Darren Shu Jeng Ting ◽  
Tushar Agarwal ◽  
Jacqueline Beltz ◽  
...  
Keyword(s):  
Risk Factors ◽  
Preventive Measures ◽  
Endothelial Keratoplasty ◽  
Common Complication ◽  
Prevention Measures ◽  
Descemet Stripping Endothelial Keratoplasty ◽  
Secondary Interventions ◽  
Different Types ◽  
Incidence Risk ◽  
Donor Graft

Graft detachment is the most common complication of endothelial keratoplasty. With the ongoing advancements in the field of endothelial keratoplasty, our understanding of risk factors of graft detachments and its management has been evolving. Various prevention measures have been described in literature including presoaking the donor graft, anterior chamber tamponade, venting incisions, sutures to prevent dislocation of graft. Management of a detached graft involves secondary interventions such as rebubbling, suturing and regrafts. In this review, we discuss graft detachment in different types of endothelial keratoplasty techniques including Descemet stripping endothelial keratoplasty, Descemet stripping automated endothelial keratoplasty and Descemet’s membrane endothelial keratoplasty; with emphasis on incidence, risk factors, preventive measures and their management.

Spinal Balance/Alignment—Clinical Relevance and Biomechanics

2019 ◽  
Vol 141 (7) ◽  
Author(s):  
Anoli Shah ◽  
Justin V. C. Lemans ◽  
Joseph Zavatsky ◽  
Aakash Agarwal ◽  
Moyo C. Kruyt ◽  
...  
Keyword(s):  
Social Interaction ◽  
Sagittal Balance ◽  
Sagittal Plane ◽  
The Body ◽  
Optimal Configuration ◽  
Sacral Slope ◽  
Sagittal Imbalance ◽  
Compensatory Mechanisms ◽  
Spinal Balance ◽  
Spinal Imbalance

In the anatomy of a normal spine, due to the curvatures in various regions, the C7 plumb line (C7PL) passes through the sacrum so that the head is centered over the pelvic-ball and socket hip and ankle joints. A failure to recognize malalignment in the sagittal plane can affect the patient's activity as well as social interaction due to deficient forward gaze. The sagittal balance configuration leads to the body undertaking the least muscular activities as possible necessary to maintain spinal balance. Global sagittal imbalance is energy consuming and often results in painful compensatory mechanisms that in turn negatively influence the patient's quality of life, self-image, and social interaction due to inability to maintain a horizontal gaze. Deformity, scoliosis, kyphosis, trauma, and/or surgery are some ways that this optimal configuration can be disturbed, thus requiring higher muscular activity to maintain posture and balance. Several parameters such as the thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), and hip and leg positions influence the sagittal balance and thus the optimal configuration of spinal alignment. This review examines the clinical and biomechanical aspects of spinal imbalance, and the biomechanics of spinal balance as dictated by deformities—ankylosing spondylitis (AS), scoliosis and kyphosis; surgical corrections—pedicle subtraction osteotomies (PSO), long segment stabilizations, and consequent postural complications like proximal and distal junctional kyphosis. The study of the biomechanics involved in spinal imbalance is relatively new and thus the literature is rather sparse. This review suggests several potential research topics in the area of spinal biomechanics.

scholarly journals Sagittal profile modifications in hybrid versus all screw technique in adolescent idiopathic scoliosis

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Laura Scaramuzzo ◽  
Antonino Zagra ◽  
Giuseppe Barone ◽  
Stefano Muzzi ◽  
Leone Minoia ◽  
...  
Keyword(s):  
Adolescent Idiopathic Scoliosis ◽  
Idiopathic Scoliosis ◽  
Cobb Angle ◽  
Thoracic Kyphosis ◽  
Sagittal Alignment ◽  
Vertical Axis ◽  
Sagittal Profile ◽  
Sacral Slope ◽  
Sagittal Vertical Axis ◽  
Lenke Classification

AbstractAim of the study was to evaluate sagittal parameters modifications, with particular interest in thoracic kyphosis, in patients affected by adolescent idiopathic scoliosis (AIS) comparing hybrid and all-screws technique. From June 2010 to September 2018, 145 patients were enrolled. Evaluation included: Lenke classification, Risser scale, coronal Cobb angle, thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS). Patients were divided in two groups (1 all-screws and 2 hybrid); a further division, in both groups, was done considering preoperative TK values. Descriptive and inferential statistical analysis was conducted. 99 patients were in group 1, 46 in group 2 (mean follow-up 3.7 years). Patients with a normo-kyphotic profile developed a little variation in TK (Δ pre–post = 2.4° versus − 2.0° respectively). Hyper-kyphotic subgroups had a tendency of restoring a good sagittal alignment. Hypo-kyphotic subgroups, patients treated with all-screw implants developed a higher increase in TK mean Cobb angle (Δ pre–post = 10°) than the hybrid subgroup (Δ pre–post = 5.4°) (p = 0.01). All-screws group showed better results in restoring sagittal alignment in all subgroups compared to hybrid groups, especially in hypo-TK subgroup, with the important advantage to give better correction on coronal plane.

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