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Aaron J. Clark, Jessica A. Tang, Jeremi M. Leasure, Michael E. Ivan, Dimitriy Kondrashov, Jenni M. Buckley, Vedat Deviren and Christopher P. Ames

fatigue loading, the slope of the cephalad L-3 endplate was monitored with a goniometer. The slope at maximum loading every 1000 cycles was compared with the initial slope. If the change in maximum loading slope exceeded 20°, the test was stopped and was noted as failure. The cycle count to failure was recorded for each specimen. Following fatigue loading, each specimen was subjected to FE ROM testing to evaluate the stability of the construct postfatigue. This simulated a significant change in lower lumbar angulation, which could impact standing sagittal alignment

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Justin S. Smith, Christopher I. Shaffrey, Virginie Lafage, Benjamin Blondel, Frank Schwab, Richard Hostin, Robert Hart, Brian O'Shaughnessy, Shay Bess, Serena S. Hu, Vedat Deviren, Christopher P. Ames and International Spine Study Group

P ositive sagittal malalignment (defined as anterior deviation of the C-7 plumb line >5 cm from the posterior superior corner of S-1) is recognized as a cause of pain and disability in cases of ASD. 8 , 20 , 28 , 30 , 31 Poor sagittal alignment has been shown to require increased energy expenditure, and multiple compensatory measures have been described, including knee flexion, pelvic retroversion, and thoracic hypokyphosis. 20 , 30 , 31 Surgical correction of positive sagittal malalignment has been correlated with significant improvement in health

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Justin K. Scheer, Jessica A. Tang, Justin S. Smith, Frank L. Acosta Jr., Themistocles S. Protopsaltis, Benjamin Blondel, Shay Bess, Christopher I. Shaffrey, Vedat Deviren, Virginie Lafage, Frank Schwab, Christopher P. Ames and the International Spine Study Group

bodies from C-2 to C-7 and then summing the segmental angles for an overall cervical curvature angle. Translation of the cervical spine in the sagittal plane is measured through the cervical SVA, for which there are different methods of measurement. Both C-2 SVA ( Figs. 2 and 3 left ) and C-7 SVA have been used to define sagittal alignment globally by measuring the distance between the C-2 and C-7 plumb lines, respectively, from the posterior superior corner of the sacrum. Cervical SVA can also be defined regionally using the distance between a plumb line dropped

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Darryl Lau, Joseph A. Osorio, Vedat Deviren and Christopher P. Ames

. 13 It has been established that global sagittal alignment and coronal spinal alignment are strongly correlated with functional disability and pain outcomes, as has been validated by various health-related quality of life scores (HRQLS)—greater imbalance leading to greater functional disability. 12 , 14 , 21 , 39 Fortunately, the surgical correction and reestablishment of age-appropriate global spinal alignment and spinopelvic parameters have been demonstrated to significantly improve patient function, pain, and appearance. 19 , 29 , 36 In general, the objective

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Christopher P. Ames, Justin S. Smith, Robert Eastlack, Donald J. Blaskiewicz, Christopher I. Shaffrey, Frank Schwab, Shay Bess, Han Jo Kim, Gregory M. Mundis Jr., Eric Klineberg, Munish Gupta, Michael O’Brien, Richard Hostin, Justin K. Scheer, Themistocles S. Protopsaltis, Kai-Ming G. Fu, Robert Hart, Todd J. Albert, K. Daniel Riew, Michael G. Fehlings, Vedat Deviren, Virginie Lafage and International Spine Study Group

posterosuperior corner of the C-7 vertebral body. The horizontal line with an arrow represents the C2–7 SVA. Given the significant impact of sagittal alignment on HRQOL among patients with thoracolumbar spinal deformities, and the studies of Tang et al. 54 and Smith et al. 45 demonstrating correlations between cervical sagittal alignment and multiple measures of HRQOL, the C2–7 SVA was selected as a modifier for the CSD classification. Based on regression analysis from Tang et al., a C2–7 SVA threshold of 4 cm was found to correlate with moderate disability based on the

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Justin S. Smith, Christopher I. Shaffrey, Virginie Lafage, Frank Schwab, Justin K. Scheer, Themistocles Protopsaltis, Eric Klineberg, Munish Gupta, Richard Hostin, Kai-Ming G. Fu, Gregory M. Mundis Jr., Han Jo Kim, Vedat Deviren, Alex Soroceanu, Robert A. Hart, Douglas C. Burton, Shay Bess, Christopher P. Ames and the International Spine Study Group

Slover J , Abdu WA , Hanscom B , Weinstein JN : The impact of comorbidities on the change in short-form 36 and Oswes-try scores following lumbar spine surgery . Spine (Phila Pa 1976) 31 : 1974 – 1980 , 2006 41 Smith JS , Bess S , Shaffrey CI , Burton DC , Hart RA , Hostin R , : Dynamic changes of the pelvis and spine are key to predicting postoperative sagittal alignment after pedicle subtraction osteotomy: a critical analysis of preoperative planning techniques . Spine (Phila Pa 1976) 37 : 845 – 853 , 2012 42 Smith JS , Fu

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Justin S. Smith, Ellen Shaffrey, Eric Klineberg, Christopher I. Shaffrey, Virginie Lafage, Frank J. Schwab, Themistocles Protopsaltis, Justin K. Scheer, Gregory M. Mundis Jr., Kai-Ming G. Fu, Munish C. Gupta, Richard Hostin, Vedat Deviren, Khaled Kebaish, Robert Hart, Douglas C. Burton, Breton Line, Shay Bess, Christopher P. Ames and The International Spine Study Group

fracture, the retrospective study suggested that residual postoperative sagittal malalignment and greater BMI may be associated with greater risk of rod fracture. The present prospective study confirms the added risk of rod fracture with greater BMI and confirms that sagittal spinopelvic alignment may also be a risk factor, but instead of postoperative residual sagittal malalignment, the present study suggests that it is the magnitude of sagittal alignment correction that may be a more important factor. The findings of the present study demonstrate a markedly higher

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Russell G. Strom, Junseok Bae, Jun Mizutani, Frank Valone III, Christopher P. Ames and Vedat Deviren

More recently, LIF has been adopted in the treatment of ASD. 1 , 4 , 7 , 24 , 28 LIF is effective for coronal plane deformities, 24 but only mild improvement in sagittal alignment has been reported. Acosta et al. reported a mean 11.7° lumbar coronal Cobb angle correction in patients with degenerative scoliosis. 1 Mean LL restoration was only 4.1°, and there was no significant improvement in SVA. 1 Park et al. reported more LL restoration when LIF was coupled with open instead of percutaneous screw fixation (8° vs 3°, respectively). 23 Other studies have reported

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Christopher P. Ames, Justin S. Smith, Justin K. Scheer, Shay Bess, S. Samuel Bederman, Vedat Deviren, Virginie Lafage, Frank Schwab and Christopher I. Shaffrey

posterior, respectively, to the posterosuperior corner of the S-1 vertebral body. The T-1 spinopelvic inclination 30 and the T9SPI are alternative measures of SA. These measures are angles between the vertical plumb line extended from the bicoxofemoral axis and lines drawn from the vertebral body center of T-1 or T-9 to the center of the bicoxofemoral axis ( Fig. 3 right ). Since the T-1 and T-9 inclinations are angles rather than measured lines, they are not prone to radiographic magnification issues. Sagittal alignment is also assessed through regional measures of

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Dominic Amara, Praveen V. Mummaneni, Christopher P. Ames, Bobby Tay, Vedat Deviren, Shane Burch, Sigurd H. Berven and Dean Chou

(PI), pelvic tilt (PT), lumbar lordosis (LL), pelvic incidence–lumbar lordosis (PI-LL) mismatch, sagittal vertical axis (SVA), coronal vertical axis (CVA), and major curve magnitude. The proportion of patients with sagittal alignment and sagittal malalignment in each of the three groups was noted as well. Patients were considered to be well aligned if their SVA was < 5 cm, their PT was < 20°, and the difference between their PI and LL was < 10°. FIG. 2. Illustrations showing FC-only fusion (L4–S1, A ), sacrum to lower thoracic fusion (T10, B ) and sacrum to upper