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Emmanuelle Ferrero, Barthelemy Liabaud, Jensen K. Henry, Christopher P. Ames, Khaled Kebaish, Gregory M. Mundis, Richard Hostin, Munish C. Gupta, Oheneba Boachie-Adjei, Justin S. Smith, Robert A. Hart, Ibrahim Obeid, Bassel G. Diebo, Frank J. Schwab and Virginie Lafage

timing of revision surgery (up to 2 years postoperatively). Radiographic Measurement Radiographs were analyzed using validated software (Spineview, ENSAM Paris-Tech). 34 Sagittal spinopelvic radiographic parameters included cervical lordosis, T2–12 thoracic kyphosis (TK), LL, PI-LL mismatch, and pelvic parameters (PI, PT, and sacral slope). 46 Global sagittal alignment parameters included SVA and T-1 spinopelvic inclination (T1SPi) ( Fig. 1 ). The 3CO resection angle was defined as the change in the angle formed by the upper endplate of the vertebra below the 3CO and

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Themistocles S. Protopsaltis, Justin K. Scheer, Jamie S. Terran, Justin S. Smith, D. Kojo Hamilton, Han Jo Kim, Greg M. Mundis Jr., Robert A. Hart, Ian M. McCarthy, Eric Klineberg, Virginie Lafage, Shay Bess, Frank Schwab, Christopher I. Shaffrey, Christopher P. Ames and International Spine Study Group

A dult spinal deformity has been studied extensively in the literature with a majority of publications focusing on thoracolumbar deformity and its effect on health-related quality of life (HRQOL) measures. 1 , 3 , 6 , 7 , 10 , 11 , 13 , 14 , 16 , 17 Among patients with thoracolumbar deformities, positive sagittal alignment has been associated with pain and disability. 2 , 7 , 11 , 13 , 16 Few studies have correlated validated health measures and positive cervical sagittal alignment. 16 , 17 Tang et al. 16 demonstrated that a C2–7 sagittal vertical axis

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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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Renaud Lafage, Ibrahim Obeid, Barthelemy Liabaud, Shay Bess, Douglas Burton, Justin S. Smith, Cyrus Jalai, Richard Hostin, Christopher I. Shaffrey, Christopher Ames, Han Jo Kim, Eric Klineberg, Frank Schwab, Virginie Lafage and the International Spine Study Group

levels above UIV. Statistical Analysis The collected demographic, surgical, and radiographic data were described and analyzed at baseline and immediate postoperative follow-up. Changes in radiographic alignment were also investigated, including a preoperative to postoperative analysis of sagittal alignment and the rate of radiographic PJK. Patients were stratified into 5 groups based on the preoperative to postoperative degree of change in LL: decrease in LL (kyphotic change > 5°), stable (change between −5° and 5°), 5°–15° increase (lordotic change of 5°–15°), 15

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Virginie Lafage, Frank Schwab, Shaleen Vira, Robert Hart, Douglas Burton, Justin S. Smith, Oheneba Boachie-Adjei, Alexis Shelokov, Richard Hostin, Christopher I. Shaffrey, Munish Gupta, Behrooz A. Akbarnia, Shay Bess and Jean-Pierre Farcy

S pinal deformity in the adult is commonly a 3D pathology. However, evidence points toward the clinical impact of deformity being mostly related to the sagittal plane, with little correlation between coronal deformity and self-reported disability. The Classification of Adult Deformity 20 was primarily built on clinical impact parameters, and it highlights lumbar lordosis as well as global sagittal alignment. Work leading to the classification did not identify a significant clinical impact of coronal plane parameters. 20 Additionally, in the commonly known

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Christopher I. Shaffrey and Justin S. Smith

of the sagittal vertical axis, pelvic tilt, and the relationship between lumbar lordosis and pelvic incidence. 2 This lack of data has made direct comparison of minimally invasive and open deformity techniques difficult. A major concern following review of the cases included in the various reported minimally invasive case series is the general failure to restore normal sagittal alignment and adequate lumbar lordosis. Until now, there has been no prospective series with greater than 2 years of follow-up containing both HRQOL data and a contemporary radiographic

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Justin S. Smith, Christopher I. Shaffrey, Christopher P. Ames and Lawrence G. Lenke

relationship between global sagittal alignment (GSA) and health-related quality of life. 15 Subsequent studies have confirmed this relationship and defined the importance of pelvic morphology and alignment. 70 Global coronal alignment and GSA can be assessed based on standing full-length spine radiographs ( Fig. 3A and B ). GSA can be expressed as the sagittal vertical axis (SVA; Fig. 3B ). Alternatively, thoracic spinopelvic inclination ( Fig. 3B ) or novel measures, such as the T1 pelvic angle, 55 can be used to quantify GSA. Basic regional measures of sagittal

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Justin K. Scheer, Peter G. Passias, Alexandra M. Sorocean, Anthony J. Boniello, Gregory M. Mundis Jr., Eric Klineberg, Han Jo Kim, Themistocles S. Protopsaltis, Munish Gupta, Shay Bess, Christopher I. Shaffrey, Frank Schwab, Virginie Lafage, Justin S. Smith, Christopher P. Ames and The International Spine Study Group

, all of the demographic differences were similar between patients with and without preoperative cervical malalignment, with the exception of CK. Patients with CK were significantly younger by an average of 10 years. This result is in line with both Park et al. 20 and Smith et al. 25 The study by Park and colleagues assessed the effect of age on cervical sagittal alignment in 100 asymptomatic subjects and found that the C2–7 lordosis increased with age. Smith et al. also found that patients with CK were significantly younger than those without CK in a large

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Woojin Cho, Jonathan R. Mason, Justin S. Smith, Adam L. Shimer, Adam S. Wilson, Christopher I. Shaffrey, Francis H. Shen, Wendy M. Novicoff, Kai-Ming G. Fu, Joshua E. Heller and Vincent Arlet

larger number of failure cases. Most of the risk factors identified are related to failure of restoring proper sagittal alignment. Larger preoperative PI requires a greater correction to postoperative lumbar lordosis, 16 and less lumbar lordosis will cause less optimal sagittal alignment. 7 When the postoperative lumbar lordosis/PI mismatch was compared between the major failure and nonfailure groups, there was a significant difference in our study as shown in Table 1 (p < 0.005). Improperly restored sagittal alignment may predispose to more biomechanical stress on