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1.  Analysis of the cervical spine sagittal alignment in young idiopathic scoliosis: a morphological classification of 120 cases 
European Spine Journal  2013;22(11):2372-2381.
To analyze the relationship between the cervical spine and global spinal-pelvic alignment in young patients with idiopathic scoliosis based on a morphological classification, and to postulate the hypothesis that cervical kyphosis is a part of cervico-thoracic kyphosis in them.
120 young patients with idiopathic scoliosis were recruited retrospectively between 2006 and 2011. The following values were measured and calculated: cervical angles (CA), cervico-thoracic angles (CTA), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), spinal sacral angle (SSA), hip to C7/hip to sacrum, thoracic kyphosis (TK), lumbar lordosis (LL), Roussouly sagittal classification, Lenke Type Curve and Lumbar Modifier. The cervical curves were classified as lordosis, straight, sigmoid and kyphosis. They were categorized into four groups as cervical non-kyphosis group (CNK Group), cervical kyphosis group (CK Group), cervical-middle-thoracic kyphosis group (CMTK Group), and cervical-lower-thoracic kyphosis group (CLTK Group) according to their morphological characters of sagittal alignments. All parameters were compared and analyzed among groups.
The incidence of cervical kyphosis was 40 % (48/120). The CA and the CTA were in significant correlation (r = 0.854, P = 0.00). The cervical spine alignments were revealed to be significantly different among groups (r = 85.04, P = 0.00). Significant differences among groups in CA, CTA and TK were also detected. A strong correlation between the group type and Lenke Lumbar Modifier was still seen (P < 0.05). Fisher’s exact test revealed that the individual vertebral body kyphosis and wedging were directly related to the overall cervical kyphosis (P = 0.00, respectively).
The cervical kyphosis is correlated with global sagittal alignment, and is a part of cervico-thoracic sagittal deformity in young patients with idiopathic scoliosis. Despite the deformity in cervical alignment, the global spine could still be well-balanced with spontaneous adjustment. The correlation between our grouping based on the morphological characteristics of the sagittal alignments and Lenke Lumbar Modifier suggests that the coupled motion principle be appropriate to explain the modifications both in coronal and sagittal planes.
PMCID: PMC3886525  PMID: 23580056
Young idiopathic scoliosis; Cervical kyphosis; Cervico-thoracic sagittal alignment groups; Global sagittal alignment
2.  Compensatory mechanisms contributing to keep the sagittal balance of the spine 
European Spine Journal  2013;22(Suppl 6):834-841.
Aging spine is characterized by facet joints arthritis, degenerative disc disease, bone remodeling and atrophy of extensor muscles resulting in a progressive kyphosis of the lumbar spine.
The aim of this paper is to describe the different compensatory mechanisms for patients with severe degenerative lumbar spine.
Material and methods
According to the severity of the imbalance, three stages are observed: balanced, balanced with compensatory mechanisms and imbalanced. For the two last stages, the compensatory mechanisms permit to limit the consequences of loss of lumbar lordosis on global sagittal alignment and therefore contribute to keep the sagittal balance of the spine.
The basic concept is to extend adjacent segments of the kyphotic spine allowing for compensation of the sagittal unbalance but potentially inducing adverse effects.
Finally, we propose a three-step algorithm to analyze the global balance status and take into consideration the presence of the compensatory mechanisms in the spinal, pelvic and lower limb areas.
PMCID: PMC3830026  PMID: 24052406
Sagittal balance; Pelvis; Spinal alignment; Lumbar lordosis; Degenerative disc disease; Lumbar kyphosis
3.  Pre- and post-operative sagittal balance in idiopathic scoliosis: a comparison over the ages of two cohorts of 132 adolescents and 52 adults 
European Spine Journal  2012;22(Suppl 2):203-215.
Study design
Retrospective study of a prospective clinical and radiological database of subjects with adolescent (AIS) and adult (AS) idiopathic scoliosis undergoing surgical correction by posterior approach.
To evaluate the differences in sagittal alignment of the spine and pelvis in AIS and AS before surgery and changes after surgery in both populations.
Summary of background data
The relationship between the spine and pelvis highly influences the sagittal balance in adults and adolescents. However, the sagittal alignment of the spine and pelvis before and after surgery in idiopathic scoliosis, whatever the age, is poorly defined in the literature.
Clinical and radiological data were extracted from a prospective database of 132 AIS patients and 52 AS before and at last follow-up after surgical correction. Sagittal parameters were evaluated on AP and lateral radiographs using a custom software: pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), lumbar lordosis (LL), thoracic kyphosis (TK), C7 Barrey’s ratio, spino-sacral angle (SSA). A new algorithm of combination of balance parameters was proposed to characterize and compare the various pathological spino-pelvic settings. Based on PI subdivision in high (<55°) and low values (>55°), then on a range of PT indexed on PI giving the pelvis positioning (anteverted, normal or retroverted), the population was finally characterized by the C7 plumbline position with regard to the posterior edge of the sacrum and the center of the femoral heads, in balanced, slightly unbalanced and unbalanced. More specifically, the AIS study included the cervical shape alignment with cervical lordosis (CL) and sagittal thoracic profile assessment (hypo vs. normokyphotic). In AS, the study focused on thoraco-lumbar kyphosis (TLK) occurrence (LL length). Paired Student t tests were used for comparison (α = 0.02).
Pre-operatively, in AIS there was a prevalence of lower PI (57 %). Whatever the PI, PT remained anteverted or normal. Positioning of C7 was much more unbalanced, forward of the femoral heads (50 %), than in asymptomatic population (17 %). There was a notable loss and reversal of cervical lordosis in the majority of subjects, with an average cervical kyphosis measurement of 10 ± 18°. Thoracic kyphosis values were lower than average, while lumbar lordosis values were within normal limits. After surgery, in the entire group, a slight but significant increase of PT coupled to a decrease of SS and LL was noted, while no changes could be documented in thoracic kyphosis and cervical lordosis. However, when sub-classified according to thoracic hypo versus normokyphosis pre-op, there was a significant decrease of TK coupled to a decrease of LL and CL in the normokyphotic group, while TK and CL were improved in the hypokyphotic group. A significant number of patients improved their global balance. Changes in sagittal profile between Lenke curve types were minimal. In AS there were significant differences between low and high PI populations. Severity of unbalance increased in high PI population with association of retroverted pelvis and forward unbalance. In lower PI, increasing PT was generally sufficient to balance the patients. The occurrence of TLK was strongly increased in the entire population and became the rule in those with lower PI (76 %). Post-operatively, in those with high PI, PT did not change while global balance improved slightly. The strategy of correction in higher PI was to maintain TLK. In those with low PI, PT improved while C7 did not change. Correction of TLK was obtained in eight cases.
A decrease of cervical lordosis and thoracic kyphosis is commonly associated with AIS. The anterior unbalance frequently found in AIS does not seem to have the same significance of severity as in AS. In AIS PI does not change the balance criterions, while in AS the severity of unbalance is increased with higher PI. TLK seems to be a way of worsening the balance in elderly, mainly in lumbar and thoraco-lumbar scoliosis with low PI. Surgical correction of the thoracic and lumbar spine in AIS induces significant changes in the sagittal spino-pelvic profile. Changes in the cervical sagittal profile vary according to the pre-op sagittal profile of the thoracic kyphosis. Cervical lordosis and thoracic kyphosis are improved by surgical correction in subjects with pre-operative hypokyphosis, but a reverse effect is noted in those with normal pre-operative kyphosis. The clinical significance of these changes in sagittal shape remains to be determined. In AS, it appears easier to restore a good balance in the lower PI population than in those with less pre-operative unbalance.
PMCID: PMC3616473  PMID: 23188161
Adolescent idiopathic scoliosis; Adult scoliosis; Kyphosis; Lordosis; Pelvis; Sagittal balance; Spine; Cervical spine
4.  Sagittal balance analysis after pedicle subtraction osteotomy in ankylosing spondylitis 
European Spine Journal  2011;20(Suppl 5):619-625.
This is a radiographic study of ankylosing spondylitis patients with severe fixed kyphotic deformity who underwent pedicle subtraction osteotomy. Our goal was to measure and validate new angle to assess global kyphosis and to evaluate the sagittal balance after surgery. This is the first report which describes new angle to assess global kyphosis (T1-S1).
Materials and methods
Pre and postoperative controls were compared according to the Pelvic Incidence. The sagittal parameters ankylosing spondylitis patients were compared with 154 asymptomatic patients. In addition to the pelvic parameters and the C7 tilt, we used the spino-sacral angle.
Pelvic incidence in ankylosing spondylitis patients was higher than asymptomatic population (61° vs. 51°). For a same tilt of C7 for both groups, the low pelvic incidence group had a lower sacral slope and pelvic tilt and a higher global kyphosis (spino-sacral angle = 90°) than the high pelvic incidence group (spino-sacral angle = 98°). In the adult volunteers, the C7 tilt and spino-sacral angle measured, respectively, 95° and 135°. The preoperative C7 tilt measured 73° and increased to 83° (p = 0.0025). The preoperative spino-sacral angle measured 96° and increased to 113.3° (p = 0.003).
A low pelvic incidence pelvis has a lower sacral slope than in high pelvic incidence and can support a bigger kyphosis. All the parameters were improved by the pedicle subtraction osteotomy, but the average spinosacral angle remained lower than the control group. When C7 tilt was useful to assess the improvement of the sagittal balance, SSA allowed a better evaluation of the correction of kyphosis itself.
PMCID: PMC3175913  PMID: 21830080
Kyphosis; Ankylosing spondylitis; Pedicle subtraction osteotomy; Spino-sacral-angle
5.  Biomechanical analysis of the spino-pelvic organization and adaptation in pathology 
European Spine Journal  2011;20(Suppl 5):609-618.
Standing in an erect position is a human property. The pelvis anatomy and position, defined by the pelvis incidence, interact with the spinal organization in shape and position to regulate the sagittal balance between both the spine and pelvis. Sagittal balance of the human body may be defined by a setting of different parameters such as (a) pelvic parameters: pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS); (b) C7 positioning: spino-pelvic angle (SSA) and C7 plumb line; (c) shape of the spine: lumbar lordosis.
Biomechanical adaptation of the spine in pathology
In case of pathological kyphosis, different mechanical compensations may be activated. When the spine remains flexible, the hyperextension of the spine below or above compensates the kyphosis. When the spine is rigid, the only way is rotating backward the pelvis (retroversion). This mechanism is limited by the value of PI. Hip extension is a limitation factor of big retroversion when PI is high. Flexion of the knees may occur when hip extension is overpassed. The quantity of global kyphosis may be calculated by the SSA. The more SSA decreases, the more the severity of kyphosis increases. We used Roussouly’s classification of lumbar lordosis into four types to define the shape of the spine. The forces acting on a spinal unit are combined in a contact force (CF). CF is the addition of gravity and muscle forces. In case of unbalance, CF is tremendously increased. Distribution of CF depends on the vertebral plate orientation. In an average tilt (45°), the two resultants, parallel to the plate (sliding force) or perpendicular (pressure), are equivalent. If the tilt increases, the sliding force is predominant. On the contrary, with a horizontal plate, the pressure increases. Importance of curvature is another factor of CF distribution. In a flat or kyphosis spine, CF acts more on the vertebral bodies and disc. In the case of important extension curvature, it is on the posterior elements that CF acts more. According to the shape of the spine, we may expect different degenerative evolution: (a) Type 1 is a long thoraco-lumbar kyphosis and a short hyperlordosis: discopathies in the TL area and arthritis of the posterior facets in the distal lumbar spine. In younger patients, L4 S1 hyperextension may induce a nutcracker L5 spondylolysis. (b) Type 2 is a flat lordosis: Stress is at its maximum on the discs with a high risk of early disc herniation than later with multilevel discopathies. (c) Type 3 has an average shape without characteristics for a specific degeneration of the spine. (d) Type 4 is a long and curved lumbar spine: this is the spine for L5 isthmic lysis by shear forces. When the patient keeps the lordosis curvature, a posterior arthritis may occur and later a degenerative L4 L5 spondylolisthesis. Older patients may lose the lordosis curvature, SSA decreases and pelvis tilt increases. A widely retroverted pelvis with a high pelvic incidence is certainly a previous Type 4 and a restoration of a big lordosis is needed in case of arthrodesis.
The genuine shape of the spine is probably one of the main mechanical factors of degenerative evolution. This shape is oriented by a shape pelvis parameter, the pelvis incidence. In case of pathology, this constant parameter is the only signature to determine the original spine shape we have to restore the balance of the patient.
PMCID: PMC3175914  PMID: 21809016
Lumbar lordosis; Spino-sacral angle; Thoracic kyphosis; Pelvic incidence; Pelvic tilt; Sacral slope; Sagittal balance; Pathological balance
6.  Sagittal parameters of the spine: biomechanical approach 
European Spine Journal  2011;20(Suppl 5):578-585.
According to the anatomical segmentation, spine curves are the sacral kyphosis (sacrum), lumbar lordosis (L1 to L5), thoracic kyphosis (T1 to T12) and cervical lordosis (C1 to C7). From the morphological point of view the vertebrae of a curve are not identical: from cranial to caudal and vice versa there is a progressive anatomical modification. Both curves of the thoraco-lumbar spine may be divided at the Inflexion Point where lordosis turns into kyphosis. A geometrical construct of each curve by two tangent arcs of circle allows understanding the reciprocal changes between both curves. Lumbar Lordosis is mainly dependent on SS orientation, and the top of thoracic curve on C7 is very stable over the sacrum. Thoracic curve is dependent on lumbar lordosis orientation and C7 positioning. On a reverse effect, structural changing of thoracic kyphosis may affect the shape of the lumbar lordosis and the orientation of the pelvis.
PMCID: PMC3175922  PMID: 21796394
Sagittal balance; Spine curves; Lordosis; Thoracic kyphosis; Geometrical analysis
7.  Pediatric sagittal alignment 
European Spine Journal  2011;20(Suppl 5):586-590.
There is a wide variation in the regional parameters used to describe the spine and sacro-pelvis in children and adolescents. There is a slight tendency for thoracic kyphosis and lumbar lordosis to increase with age. Pelvic incidence and pelvic tilt also tend to increase during growth, while sacral slope remains relatively stable. Strong knowledge of the close relationships between adjacent anatomical regions of the spine and sacro-pelvis is the key when evaluating and interpreting sagittal spino-pelvic alignment. The scheme of correlations between adjacent regional parameters needs to be preserved in order to maintain a balanced posture. The net resultant from these relationships between adjacent anatomical regions is best represented by parameters of sagittal global balance. C7 plumbline tends to move backwards from childhood to adulthood, where it stabilizes or slightly moves forward secondary to degenerative changes. C7 plumbline in front of both hip axis and center of the upper sacral endplate occurs in 29% of subjects aged 3–10 years, 12% of subjects aged between 10 and 18 years, and 14% of subjects aged 18 years or older. Therefore, although most normal subjects stand with a C7 plumbline behind the hip axis, a C7 plumbline in front of both hip axis and sacrum can be seen in normal individuals. However, progressive forward displacement of C7 plumbline should raise a suspicion for the risk of developing spinal pathology.
PMCID: PMC3175924  PMID: 21811824
Morphology; Pelvis; Posture; Sagittal alignment; Sagittal balance; Spine
8.  Sagittal spino-pelvic alignment in chronic low back pain 
European Spine Journal  2011;20(Suppl 5):634-640.
The differences in sagittal spino-pelvic alignment between adults with chronic low back pain (LBP) and the normal population are still poorly understood. In particular, it is still unknown if particular patterns of sagittal spino-pelvic alignment are more prevalent in chronic LBP. The current study helps to better understand the relationship between sagittal alignment and low back pain.
Materials and methods
To compare the sagittal spino-pelvic alignment of patients with chronic LBP with a cohort of asymptomatic adults. Sagittal spino-pelvic alignment was evaluated in prospective cohorts of 198 patients with chronic LBP and 709 normal subjects. The two cohorts were compared with respect to the sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), lumbar lordosis (LL), lumbar tilt (LT), lordotic levels, thoracic kyphosis (TK), thoracic tilt (TT), kyphotic levels, and lumbosacral joint angle (LSA). Correlations between parameters were also assessed.
Sagittal spino-pelvic alignment is significantly different in chronic LBP with respect to SS, PI, LT, lordotic levels, TK, TT and LSA, but not PT, LL, and kyphotic levels. Correlations between parameters were similar for the two cohorts. As compared to normal adults, a greater proportion of patients with LBP presented low SS and LL associated with a small PI, while a greater proportion of normal subjects presented normal or high SS associated with normal or high PI.
Sagittal spino-pelvic alignment was different between patients with chronic LBP and controls. In particular, there was a greater proportion of chronic LBP patients with low SS, low LL and small PI, suggesting the relationship between this specific pattern and the presence of chronic LBP.
PMCID: PMC3175927  PMID: 21870097
Low back pain; Pelvic morphology; Sagittal balance; Spino-pelvic alignment
9.  Spino-pelvic sagittal balance of spondylolisthesis: a review and classification 
European Spine Journal  2011;20(Suppl 5):641-646.
In L5-S1 spondylolisthesis, it has been clearly demonstrated over the past decade that sacro-pelvic morphology is abnormal and that it can be associated to an abnormal sacro-pelvic orientation as well as to a disturbed global sagittal balance of the spine. The purpose of this article is to review the work done within the Spinal Deformity Study Group (SDSG) over the past decade, which has led to a classification incorporating this recent knowledge.
Material and methods
The evidence presented has been derived from the analysis of the SDSG database, a multi-center radiological database of patients with L5-S1 spondylolisthesis, collected from 43 spine surgeons in North America and Europe.
The classification defines 6 types of spondylolisthesis based on features that can be assessed on sagittal radiographs of the spine and pelvis: (1) grade of slip, (2) pelvic incidence, and (3) spino-pelvic alignment. A reliability study has demonstrated substantial intra- and inter-observer reliability similar to other currently used classifications for spinal deformity. Furthermore, health-related quality of life measures were found to be significantly different between the 6 types, thus supporting the value of a classification based on spino-pelvic alignment.
The clinical relevance is that clinicians need to keep in mind when planning treatment that subjects with L5-S1 spondylolisthesis are a heterogeneous group with various adaptations of their posture. In the current controversy on whether high-grade deformities should or should not be reduced, it is suggested that reduction techniques should preferably be used in subjects with evidence of abnormal posture, in order to restore global spino-pelvic balance and improve the biomechanical environment for fusion.
PMCID: PMC3175928  PMID: 21809015
Spondylolisthesis; Classification; Sagittal balance; Spino-pelvic alignment
10.  Sagittal balance disorders in severe degenerative spine. Can we identify the compensatory mechanisms? 
European Spine Journal  2011;20(Suppl 5):626-633.
Aging of the spine is characterized by facet joints arthritis, degenerative disc disease and atrophy of extensor muscles resulting in a progressive kyphosis. Recent studies confirmed that patients with lumbar degenerative disease were characterized by an anterior sagittal imbalance, a loss of lumbar lordosis and an increase of pelvis tilt. The aim of this paper was thus to describe the different compensatory mechanisms which are observed in the spine, pelvis and/or lower limbs areas for patients with severe degenerative spine.
We reviewed all the compensatory mechanisms of sagittal unbalance described in the literature.
According to the severity of the imbalance, we could identify three different stages: balanced, balanced with compensatory mechanisms and imbalanced. For the two last stages, the compensatory mechanisms permitted to limit consequences of lumbar kyphosis on the global sagittal alignment. Reduction of thoracic kyphosis, intervertebral hyperextension, retrolisthesis, pelvis backtilt, knee flessum and ankle extension were the main mechanisms described in the literature. The basic concept of these compensatory mechanisms was to extend adjacent segments of the kyphotic spine allowing for compensation of anterior translation of the axis of gravity.
To avoid underestimate the severity of the degenerative spine disorder, it thus seems important to recognize the different compensatory mechanisms from the upper part of the trunk to the lower limbs. We propose a three steps algorithm to analyse the balance status and determine the presence or not of these compensatory mechanisms: measurement of pelvis incidence, assessment of global sagittal alignment and analysis of compensatory mechanisms successively in the spine, pelvis and lower limbs areas.
PMCID: PMC3175931  PMID: 21796393
Sagittal balance; Pelvis; Spinal alignment; Lumbar lordosis; Degenerative disc disease; Lumbar kyphosis
11.  Complications and Morbidities of Mini-open Anterior Retroperitoneal Lumbar Interbody Fusion: Oblique Lumbar Interbody Fusion in 179 Patients 
Asian Spine Journal  2012;6(2):89-97.
Study Design
A retrospective study including 179 patients who underwent oblique lumbar interbody fusion (OLIF) at one institution.
To report the complications associated with a minimally invasive technique of a retroperitoneal anterolateral approach to the lumbar spine.
Overview of Literature
Different approaches to the lumbar spine have been proposed, but they are associated with an increased risk of complications and a longer operation.
A total of 179 patients with previous posterior instrumented fusion undergoing OLIF were included. The technique is described in terms of: the number of levels fused, operative time and blood loss. Persurgical and postsurgical complications were noted.
Patients were age 54.1 ± 10.6 with a BMI of 24.8 ± 4.1 kg/m2. The procedure was performed in the lumbar spine at L1-L2 in 4, L2-L3 in 54, L3-L4 in 120, L4-L5 in 134, and L5-S1 in 6 patients. It was done at 1 level in 56, 2 levels in 107, and 3 levels in 16 patients. Surgery time and blood loss were, respectively, 32.5 ± 13.2 minutes and 57 ± 131 ml per level fused. There were 19 patients with a single complication and one with two complications, including two patients with postoperative radiculopathy after L3-5 OLIF. There was no abdominal weakness or herniation.
Minimally invasive OLIF can be performed easily and safely in the lumbar spine from L2 to L5, and at L1-2 for selected cases. Up to 3 levels can be addressed through a 'sliding window'. It is associated with minimal blood loss and short operations, and with decreased risk of abdominal wall weakness or herniation.
PMCID: PMC3372554  PMID: 22708012
Anterior approach; Interbody fusion; Lumbar spine; Minimally invasive surgery
12.  Sagittal plane deformity: an overview of interpretation and management 
European Spine Journal  2010;19(11):1824-1836.
The impact of sagittal plane alignment on the treatment of spinal disorders is of critical importance. A failure to recognise malalignment in this plane can have significant consequences for the patient not only in terms of pain and deformity, but also social interaction due to deficient forward gaze. A good understanding of the principles of sagittal balance is vital to achieve optimum outcomes when treating spinal disorders. Even when addressing problems in the coronal plane, an awareness of sagittal balance is necessary to avoid future complications. The normal spine has lordotic curves in the cephalad and caudal regions with a kyphotic curve in between. Overall, there is a positive correlation between thoracic kyphosis and lumbar lordosis. There are variations on the degree of normal curvature but nevertheless this shape allows equal distribution of forces across the spinal column. It is the disruption of this equilibrium by pathological processes or, as in most cases, ageing that results in deformity. This leads to adaptive changes in the pelvis and lower limbs. The effects of limb alignment on spinal posture are well documented. We now also know that changes in pelvic posture also affect spinal alignment. Sagittal malalignment presents as an exaggeration or deficiency of normal lordosis or kyphosis. Most cases seen in clinical practise are due to kyphotic deformity secondary to inflammatory, degenerative or post-traumatic disorders. They may also be secondary to infection or tumours. There is usually pain and functional disability along with concerns about self-image and social interaction due to inability to maintain a horizontal gaze. The resultant pelvic and lower limb posture is an attempt to restore normal alignment. Addressing this complex problem requires detailed expertise and awareness of the potential pitfalls surrounding its treatment.
PMCID: PMC2989270  PMID: 20567858
Sagittal; Deformity; Alignment; Angles; Management
13.  Radiological analysis of ankylosing spondylitis patients with severe kyphosis before and after pedicle subtraction osteotomy 
European Spine Journal  2009;19(1):65-70.
This is a radiographic study of ankylosing spondylitis patients with severe fixed kyphotic deformity who underwent pedicle subtraction osteotomy. Our goal was to measure and validate new angle to assess global kyphosis and to evaluate the radiological outcomes after surgery. This is the first report which describes new angle to assess global kyphosis (T1-S1). Pre and postoperative controls were compared according to the Pelvic Incidence. The sagittal parameters ankylosing spondylitis patients were compared with 154 asymptomatic patients. In addition to the pelvic parameters and the C7 tilt, we used the spino-sacral angle. Pelvic incidence in ankylosing spondylitis patients was higher than asymptomatic population (61 vs. 51°). For a same tilt of C7 for both groups, the low pelvic incidence group had a lower sacral slope and pelvic tilt and a higher global kyphosis (spino-sacral angle = 90°) than the high pelvic incidence group (spino-sacral angle = 98°). In the adult volunteers, the C7 tilt and spino-sacral angle measured, respectively, 95 and 135°. The preoperative C7 tilt measured 73° and increased to 83° (p = 0.0025). The preoperative spino-sacral angle measured 96° and increased to 113.3° (p = 0.003). A low pelvic incidence pelvis has a lower sacral slope than in high pelvic incidence and can support a bigger kyphosis. All the parameters were improved by the pedicle subtraction osteotomy, but the average spino-sacral angle remained lower than the control group. When C7 tilt was useful to assess the improvement of the balance, SSA allowed a better evaluation of the correction of kyphosis itself.
PMCID: PMC2899727  PMID: 19763635
Kyphosis; Ankylosing spondylitis; Pedicle subtraction osteotomy; Spino-sacral angle
14.  Intra- and inter-observer reliability of determining radiographic sagittal parameters of the spine and pelvis using a manual and a computer-assisted methods 
European Spine Journal  2008;17(10):1373-1379.
Sagittal imbalance is a significant factor in determining clinical treatment outcomes in patients with deformity. Measurement of sagittal alignment using the traditional Cobb technique is frequently hampered by difficulty in visualizing landmarks. This report compares traditional manual measurement techniques to a computer-assisted sagittal plane measurement program which uses a radius arc methodology. The intra and inter-observer reliability of the computer program has been shown to be 0.92–0.99. Twenty-nine lateral 90 cm radiographs were measured by a computer program for an array of sagittal plane measurements. Ten experienced orthopedic spine surgeons manually measured the same parameters twice, at least 48 h apart, using a digital caliper and a standardized radiographic manual. Intraclass correlations were used to determine intra- and interobserver reliability between different manual measures and between manual measures and computer assisted-measures. The inter-observer reliability between manual measures was poor, ranging from −0.02 to 0.64 for the different sagittal measures. The intra-observer reliability in manual measures was better ranging from 0.40 to 0.93. Comparing manual to computer-assisted measures, the ICC ranged from 0.07 to 0.75. Surgeons agreed more often with each other than with the machine when measuring the lumbar curve, the thoracic curve, and the spino-sacral angle. The reliability of the computer program is significantly higher for all measures except for lumbar lordosis. A computer-assisted program produces a reliable measurement of the sagittal profile of the spine by eliminating the need for distinctly visible endplates. The use of a radial arc methodology allows for infinite data points to be used along the spine to determine sagittal measurements. The integration of this technique with digital radiography’s ability to adjust image contrast and brightness will enable the superior identification of key anatomical parameters normally not available for measurement on traditional radiographs, improving the consistency of sagittal measurement.
PMCID: PMC2556466  PMID: 18726124
Sagittal spine alignment; Reliability; Computer measures
15.  Spino-pelvic alignment after surgical correction for developmental spondylolisthesis 
European Spine Journal  2008;17(9):1170-1176.
This study is a retrospective multi-centre analysis of changes in spino-pelvic sagittal alignment after surgical correction of L5–S1 developmental spondylolisthesis. The purpose of this study was to determine how sagittal spino-pelvic alignment is affected by surgery, with the hypothesis that surgical correction at the lumbo-sacral level is associated with an improvement in the shape of the spine and in the orientation of the pelvis. Whether L5–S1 high grade spondylolisthesis should or should not be reduced remains a controversial subject. A popular method of treatment has been in situ fusion, but studies have reported a high rate of pseudarthrosis, slip progression and persistent cosmetic deformity. Spinal instrumentation with pedicle screws has generated a renewed interest for reduction, but the indications for this treatment and its effect on spino-pelvic alignment remain poorly defined. Recent evidence indicates that reduction might be indicated for subjects with an unbalanced (retroverted or vertical) pelvis. This is a retrospective multi-centre analysis of 73 subjects (mean age 18 ± 3 years) with developmental spondylolisthesis and an average follow-up of 1.9 years after reduction and posterior fusion with spinal instrumentation or cast immobilisation. Spinal and pelvic alignment were measured on standing lateral digitised X-rays using a computer software allowing a very high inter and intra observer reliability. Pelvic incidence was unaffected by surgery. The most important changes were noted for grade, L5 Incidence, lumbo-sacral-angle, and lumbar lordosis, which all decreased significantly towards normal adult values. At first evaluation, pelvic tilt, sacral slope and thoracic kyphosis appeared minimally affected by surgery. However, after classifying subjects into balanced and unbalanced pelvis, significant improvements were noted in pelvic alignment in both the sub-groups, with 40% of cases switching groups, the majority from an unbalanced to a balanced pelvis alignment. The direction and magnitude of these changes were significantly different by sub-group: sacral slope decreased in the balanced pelvis group but increased in the unbalanced group, while pelvic tilt values did the opposite. While pelvic shape is unaffected by attempts at surgical reduction, proper repositioning of L5 over S1 significantly improves pelvic balance and lumbar shape by decreasing the abnormally high lumbar lordosis and abnormal pelvic retroversion. These results emphasise the importance of sub-dividing subjects with high grade developmental spondylolisthesis into unbalanced and balanced pelvis groups, and further support the contention that reduction techniques might be considered for the unbalanced retroverted pelvis sub-group.
PMCID: PMC2527424  PMID: 18600350
Spondylolisthesis; Surgery; Sagittal alignment; Posture
16.  Sagittal balance of the pelvis-spine complex and lumbar degenerative diseases. A comparative study about 85 cases 
European Spine Journal  2007;16(9):1459-1467.
Retrospective analysis of the spino-pelvic alignment in a population of 85 patients with a lumbar degenerative disease. Several previous publications reported the analysis of spino-pelvic alignment in the normal and low back pain population. Data suggested that patients with lumbar diseases have variations of sagittal alignment such as less distal lordosis, more proximal lumbar lordosis and a more vertical sacrum. Nevertheless most of these variations have been reported without reference to the pelvis shape which is well-known to strongly influence spino-pelvic alignment. The objective of this study was to analyse spino-pelvic parameters, including pelvis shape, in a population of 85 patients with a lumbar degenerative disease and compare these patients with a control group of normal volunteers. We analysed three different lumbar degenerative diseases: disc herniation (DH), n = 25; degenerative disc disease (DDD), n = 32; degenerative spondylolisthesis (DSPL), n = 28. Spino-pelvic alignment was analysed pre-operatively on full spine radiographs. Spino-pelvic parameters were measured as following: pelvic incidence, sacral slope, pelvic tilt, lumbar lordosis, thoracic kyphosis, spino-sacral angle and positioning of C7 plumb line. For each group of patients the sagittal profile was compared with a control population of 154 asymptomatic adults that was the subject of a previous study. In order to understand variations of spino-pelvic parameters in the patients’ population a stratification (matching) according to the pelvic incidence was done between the control group and each group of patients. Concerning first the pelvis shape, patients with DH and those with DDD demonstrated to have a mean pelvic incidence equal to 49.8° and 51.6°, respectively, versus 52° for the control group (no significant difference). Only young patients, less than 45 years old, with a disc disease (DH or DDD) demonstrated to have a pelvic incidence significantly lower (48.3°) than the control group, P < 0.05. On the contrary, in the DSPL group the pelvic incidence was significantly greater (60°) than the control group (52°), P < 0.0005. Secondly the three groups of patients were characterized by significant variations in spino-pelvic alignment: anterior translation of the C7 plumb line (P < 0.005 for DH, P < 0.05 for DDD and P < 0.05 for DSPL); loss of lumbar lordosis after matching according to pelvic incidence (P < 0.0005 for DH, DDD and DSPL); decrease of sacral slope after matching according to pelvic incidence (P = 0.001 for DH, P < 0.0005 for DDD and P < 0.0005 for DSPL). Measurement of the pelvic incidence and matching according to this parameter between each group of patients and the control group permitted to understand variations of spino-pelvic parameters in a population of patients.
PMCID: PMC2200735  PMID: 17211522
Sagittal balance; Pelvis shape; Pelvic incidence; Spinal alignment; Lumbar lordosis; Lumbar herniation; Spondylolisthesis
17.  Sagittal spinopelvic balance in normal children and adolescents 
European Spine Journal  2005;16(2):227-234.
The sagittal spinopelvic balance is poorly documented in normal pediatric subjects. The purpose of this study is to characterize the sagittal spinopelvic balance in the pediatric population and to evaluate the correlations between spinopelvic parameters. Seven parameters were evaluated from the lateral standing radiographs of 341 normal subjects aged 3–18 years old: thoracic kyphosis (TK), thoracic tilt (TT), lumbar lordosis (LL), lumbar tilt (LT), sacral slope (SS), pelvic tilt (PT) and pelvic incidence (PI). The mean values for the pelvic parameters were 49.1±11.0, 7.7±8.0 and 41.4±8.2° for PI, PT and SS, respectively. The mean values for the spinal parameters were 48.0±11.7, 44.0±10.9, −7.3±5.2 and −3.1±5.2° for LL, TK, LT and TT, respectively. The spinopelvic parameters were different from those reported in normal adults, but the correlations between the parameters were similar. PI was significantly related to SS and PT. Significant correlations were found between the parameters of adjacent anatomical regions. Pelvic morphology (PI) regulates sagittal sacro-pelvic orientation (SS and PT). Sacral orientation (SS) is correlated with the shape (LL) and orientation (LT) of the lumbar spine. Adjacent anatomical regions of the spine and pelvis are interdependent, and their relationships result in a stable and compensated posture, presumably to minimize energy expenditure. Results from this study could be used as an aid for the planning of surgery in pediatric patients with spinal deformity in order to restore a relatively normal sagittal spinopelvic balance.
PMCID: PMC2200687  PMID: 16311754
Kyphosis; Lordosis; Pelvic morphology; Pediatric orthopedics; Pelvis; Posture; Sagittal balance; Spine

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