L umbosacral fusion results in the dissipation of large cantilever forces onto the sacrum. 22 These forces increase with increased construct length, positive sagittal balance, and spondylolisthesis. 1 Increases in pelvic incidence also lead to larger shear forces exerted on the caudal sacral construct. 6 , 11 , 14 Pelvic incidence is thought to be an anatomical constant that strongly correlates with sagittal spinal alignment. The large forces exerted on the sacrum can lead to a variety of complications in spinal reconstruction, including pseudarthrosis
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A novel approach to sagittal balance restoration following iatrogenic sacral fracture and resulting sacral kyphotic deformity
Technical note
Patrick C. Hsieh, Stephen L. Ondra, Robert J. Wienecke, Brian A. O'Shaughnessy, and Tyler R. Koski
Anterior lumbar interbody fusion in comparison with transforaminal lumbar interbody fusion: implications for the restoration of foraminal height, local disc angle, lumbar lordosis, and sagittal balance
Patrick C. Hsieh, Tyler R. Koski, Brian A. O'Shaughnessy, Patrick Sugrue, Sean Salehi, Stephen Ondra, and John C. Liu
Nevertheless, interbody arthrodesis using autografts, allografts, or cages in combination with segmental pedicle screw instrumentation is an effective treatment for lower back pain and provides immediate structural support along with high fusion rates. 4 , 6 , 8 , 23 , 24 , 28 There is also increasing recognition of the importance of sagittal balance and its restoration in spine disease, 14 , 15 and restoration of normal spinal sagittal balance should be a primary goal of any reconstructive spine surgery. Anterior lumbar interbody fusion and TLIF are two techniques
Influence of positioning of L4–5 disc prostheses on functional outcomes and sagittal balance: 2-year follow-up of a cohort of 38 patients
Jean Meyblum, Baptiste Boukebous, Pierre Diviné, Philippe Cottin, Charles-Henri Flouzat Lachaniette, and Thierry Bégué
few have investigated the specific role of implant positioning on functional outcome and sagittal balance. 10 , 20 These studies have reported that off-centered Charité TDR devices (DePuy Spine) were more likely to result in poorer functional outcome, but the authors failed to specify the anterior or posterior nature of the off-centering. Implant positioning has biomechanical consequences that might impact the functional outcome. For instance, manufacturers recommend positioning TDR devices posteriorly, even though the compressive strength of the vertebral body is
Editorial: Sagittal balance
Lawrence G. Lenke
: Management of sagittal balance in adult spinal deformity with minimally invasive anterolateral lumbar interbody fusion: a preliminary radiographic study. Clinical article . J Neurosurg Spine [epub ahead of print March 14, 2014. DOI: 10.3171/2014.2.SPINE1347]
Progressive restoration of spinal sagittal balance after surgical correction of lumbosacral spondylolisthesis before skeletal maturity
Diala Thomas, Manon Bachy, Aurélien Courvoisier, Arnaud Dubory, Houssam Bouloussa, and Raphaël Vialle
T he relation of the pelvis to the spine has previously been overlooked as a factor in sagittal balance. Studies have shown that certain structural features of the pelvis modulate and largely determine the degree of standing lumbar lordosis, as well as the sagittal pelvic alignment and spinopelvic balance. 4 , 5 , 15 , 27 These relationships have been documented in adult volunteers 4 , 5 , 7 , 15 , 29 and in patients with spondylolisthesis. 6 , 10 , 11 , 16 , 22 , 28 Spinopelvic alignment is now recognized as crucial in the assessment of an energy
Sagittal balance of the cervical spine: an analysis of occipitocervical and spinopelvic interdependence, with C-7 slope as a marker of cervical and spinopelvic alignment
Susan Núñez-Pereira, Wolfgang Hitzl, Viola Bullmann, Oliver Meier, and Heiko Koller
connected to the thoracic spine. The overall sagittal balance of the thoracolumbar and lumbosacral spine is expected to influence the cervical spine, which should be the last regulator of the compensatory cascade, which starts at the pelvic region and aims to maintain overall balance. 13 , 19 Studies of the treatment of idiopathic scoliosis in adolescents have shown that loss of thoracic kyphosis as a result of surgical coronal plane correction of the scoliosis is associated with a postoperative increase in cervical kyphosis. 1 , 6 , 7 Studies of sagittal alignment
Influence of postoperative sagittal balance and spinopelvic parameters on the outcome of patients surgically treated for degenerative lumbar spondylolisthesis
Ingrid Radovanovic, Jennifer C. Urquhart, Venkat Ganapathy, Fawaz Siddiqi, Kevin R. Gurr, Stewart I. Bailey, and Christopher S. Bailey
spondylolisthesis. 2 , 12 , 19 To our knowledge, however, few studies have attempted to demonstrate an association between sagittal balance and postoperative outcome specific to the degenerative lumbar spondylolisthesis patient cohort. 10 , 13 Specifically, the importance of establishing an SVA < 50 mm in the degenerative lumbar spondylolisthesis population, as it is in the deformity cohort, remains unknown. The objective of the current investigation was to determine whether postoperative sagittal balance and spinopelvic alignment affects patient-rated outcome measures after
Improvement of sagittal balance and lumbar lordosis following less invasive adult spinal deformity surgery with expandable cages and percutaneous instrumentation
Clinical article
Michael Y. Wang
advances in the ability to mobilize the spine prior to realignment, decrease rates of pseudarthrosis, safely place implants for fixation, and initiate powerful corrective maneuvers will be necessary to advance the field if a minimally invasive approach is to achieve the results seen with powerful 3-column osteotomies. However, improvements in spinal instrumentation, image guidance, and ostobiologics will likely make minimally invasive ASD surgery a viable option for the increasingly aging population. Conclusions An expanding body of evidence suggests that sagittal
Management of sagittal balance in adult spinal deformity with minimally invasive anterolateral lumbar interbody fusion: a preliminary radiographic study
Clinical article
Jotham C. Manwaring, Konrad Bach, Amir A. Ahmadian, Armen R. Deukmedjian, Donald A. Smith, and Juan S. Uribe
deformity can improve some spinal parameters, more data are needed to determine its effect on sagittal balance, the radiographic measure critically linked to quality of life, function, and health status outcomes. 16 , 25 Traditionally, the primary methods for correcting sagittal imbalance have been the pedicle subtraction osteotomy (PSO) and Smith-Petersen osteotomy (SPO). 6–9 , 12 Recently, Deukmedjian et al. reported on the anatomical considerations in and several cases of MI anterior column release (ACR) as a means of correcting sagittal imbalance via a lateral MI
The importance of sagittal balance: how good is the evidence?
Peter D. Angevine and Paul C. McCormick
Sagittal balance is a concept familiar to spine deformity surgeons. Postural imbalance with displacement of the patient’s center of gravity anteriorly to the sacrum due to spinal disease is biomechanically disadvantageous and may cause significant pain and ambulatory difficulty. The evaluation of patients with sagittal imbalance involves a careful assessment of the thoracic kyphosis, lumbar lordosis, and pelvic angulation. Surgical planning prior to operative treatment involves careful study to determine the correct location and amount of sagittal
