Neutral upright sagittal spinal alignment from the occiput to the pelvis in asymptomatic adults: a review and resynthesis of the literature

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Object

An increasing emphasis is being placed on the preservation or restoration of neutral upright sagittal spinal alignment in both deformity surgery and routine spinal operations. Sagittal spinal alignment is becoming recognized as an important predictor of a patient’s outcome after spinal surgery. In this literature review, the authors analyze data obtained from previously published studies conducted to evaluate neutral upright sagittal spinal alignment from the occiput to the pelvis in asymptomatic adults.

Methods

A review of the English-language literature was conducted to identify studies conducted to evaluate neutral upright sagittal spinal (occiput–pelvis) alignment in asymptomatic adult volunteers with no spinal disease. The authors identified 12 articles that met the strict primary inclusion criteria of the current study. From these articles, 23 angles and displacements were selected to depict neutral upright sagittal occiput–pelvis alignment. Pooled estimates of the mean and variance were calculated for angles and displacements that met secondary inclusion criteria. The greatest variation in the regional spinal curves occurred in the cervical spine from C-2 to C-7, whereas the greatest focal angulation in the spine occurred from L-4 to S-1. Sagittal spinal balance was maintained in a narrow range for alignment of the spine over the pelvis and femoral heads.

Conclusions

Neutral upright sagittal occiput–pelvis alignment in asymptomatic adults has been well studied regionally. Despite a wide variation in the undulating lordotic and kyphotic regional curves from the occiput to the pelvis, sagittal spinal balance is maintained in a narrower range for alignment of the spine over the pelvis and femoral heads.

Abbreviations used in this paper:CBVA = Chin-brow to vertical angle; HA = hip axis; SD = standard deviation; STA = sagittal tilt angle; SVA = sagittal vertical axis; VB = vertebral body.

Article Information

Address reprint requests to: Charles Kuntz IV, M.D., c/o Editorial Office, The Neuroscience Institute, Department of Neurosurgery, ML 0515, 231 Albert Sabin Way, Cincinnati, Ohio 45267-0515. email: charleskuntz@yahoo.com.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Schematic illustrations of lateral radiographs of the spine from the occiput (O) to the pelvis, demonstrating regional and global neutral upright sagittal spinal alignment. Radiographic sagittal occiput–pelvis angles and displacements are depicted. PI = pelvic incidence; PT = pelvic tilt; SI = sacral inclination; SS = sacral slope.

  • View in gallery

    Schematic illustrations showing clinical measurement of the CBVA. The CBVA is defined as the angle subtended by a vertical reference line and a line parallel to the chin and brow with the neck in neutral or fixed position and the knees and hips extended. A: Normal CBVA. B: The CBVA with a lumbar kyphotic deformity.

References

1

Boulay CTardieu CHecquet JBenaim CMouilleseaux BMarty C: Sagittal alignment of spine and pelvis regulated by pelvic incidence: standard values and prediction of lordosis. Eur Spine J 15:4154222006

2

Cobb JROutline for the study of scoliosis. Edwards JW: Instructional Course Lectures Ann Arbor, MIthe American Academy of Orthopaedic Surgeons1948. 261275

3

El Fegoun ABSchwab FGamez LChampain NSkalli WFarcy JP: Center of gravity and radiographic posture analysis: a preliminary of adult volunteers and adult patients affected by scoliosis. Spine 30:153515402005

4

Gelb DELenke LGBridwell KHBlanke KMcEnery KW: An analysis of sagittal spinal alignment in 100 asymptomatic middle and older aged volunteers. Spine 20:135113581995

5

Glassman SDBridwell KDimar JRHorton WBerven SSchwab F: The impact of positive sagittal balance in adult spinal deformity. Spine 30:202420292005

6

Gore DRSepic SBGardner GM: Roentgenographic findings of the cervical spine in asymptomatic people. Spine 11:5215241986

7

Hardacker JWShuford RFCapicotto PNPryor PW: Radiographic standing cervical segmental alignment in adult volunteers without neck symptoms. Spine 22:147214801997

8

Harrison DECailliet RHarrison DDJanik TJHolland B: Reliability of centroid, Cobb, and Harrison posterior tangent methods: which to choose for analysis of thoracic kyphosis. Spine 26:E227E2342001

9

Harrison DEHarrison DDCailliet RJanik TJHolland B: Radiographic analysis of lumbar lordosis: centroid, Cobb, TRALL, and Harrison posterior tangent methods. Spine 26:E235E2422001

10

Harrison DEHarrison DDCailliet RTroyanovich SJJanik TJHolland B: Cobb method or Harrison tangent method: which to choose for lateral cervical radiographic analysis. Spine 25:207220782000

11

Hioki AMiyamoto KKodama HHosoe HNishimoto HSakaeda H: Two-level posterior lumbar interbody fusion for degenerative disc disease: improved clinical outcome with restoration of lumbar lordosis. Spine J 5:6006072005

12

Jackson RPHales C: Congruent spinopelvic alignment on standing lateral radiographs of adult volunteers. Spine 25:280828152000

13

Jackson RPMcManus AC: Radiographic analysis of sagittal plane alignment and balance in standing volunteers and patients with low back pain matched for age, sex, and size. A prospective controlled clinical study. Spine 19:161116181994

14

Jackson RPPeterson MDMcManus ACHales C: Compensatory spinopelvic balance over the hip axis and better reliability in measuring lordosis to the pelvic radius on standing lateral radiographs of adult volunteers and patients. Spine 23:175017671998

15

Kawakami MTamaki TAndo MYamada HHashizume HYoshida M: Lumbar sagittal balance influences the clinical outcome after decompression and posterolateral spinal fusion for degenerative lumbar spondylolisthesis. Spine 27:59642002

16

Korovessis PGStamatakis MVBaikousis AG: Reciprocal angulation of vertebral bodies in the sagittal plane in an asymptomatic Greek population. Spine 23:7007051998

17

Kumar MNBaklanov AChopin D: Correlation between sagittal plane changes and adjacent segment degeneration following lumbar spine fusion. Eur Spine J 10:3143192001

18

Kuntz CMorgan CJ: Neutral upright sagittal spinal alignment from the occiput to the pelvis in asymptomatic adults. Winter Clinics for Cranial and Spinal Surgery 20:2006. (Abstract)

19

Legaye JDuval-Beaupere GHecquet JMarty C: Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves. Eur Spine J 7:991031998

20

Matsunaga SOnishi TSakou T: Significance of occipitoaxial angle in subaxial lesion after occipitocervical fusion. Spine 26:1611652001

21

McGregor M: The significance of certain measurements of the skull in the diagnosis of basilar impression. Br J Radiol 21:1711811948

22

Nojiri KMatsumoto MChiba KMaruiwa HNakamura MNishizawa T: Relationship between alignment of upper and lower cervical spine in asymptomatic individuals. J Neurosurg 99:1 Suppl80832003

23

Roussouly PGollogly SNoseda OBerthonnaud EDimnet J: The vertical projection of the sum of the ground reactive forces of a standing patient is not the same as the C7 plumb line: a radiographic study of the sagittal alignment of 153 asymptomatic volunteers. Spine 31:E320E3252006

24

Shoda NTakeshita KSeichi AAkune TNakajima SAnamizu Y: Measurement of occipitocervical angle. Spine 29:E204E2082004

25

Silber JSLipetz JSHayes VMLonner BS: Measurement variability in the assessment of sagittal alignment of the cervical spine: a comparison of the gore and cobb methods. J Spinal Disord Tech 17:3013052004

26

Suk KKim KLee SKim J: Significance of chin-brow vertical angle in correction of kyphotic deformity of ankylosing spondylitis patients. Spine 28:200120052003

27

Van Royen BJToussaint HMKingma IBot SDCaspers MHarlaar J: Accuracy of the sagittal vertical axis in a standing lateral radiograph as a measure of balance in spinal deformities. Eur Spine J 7:4084121998

28

Vedantam RLenke LGBridwell KHLinville DLBlanke K: The effect of variation in arm position on sagittal spinal alignment. Spine 25:220422092000

29

Vialle RLevassor NRillardon LTemplier ASkalli WGuigui P: Radiographic analysis of the sagittal alignment and balance of the spine in asymptomatic subjects. J Bone Joint Surg Am 87:2602672005

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