J Korean Soc Spine Surg.  2009 Jun;16(2):142-151. 10.4184/jkss.2009.16.2.142.

Sagittal Imbalance

• Kim KT
• Lee JH

• KMID: 2209610
• DOI: http://doi.org/10.4184/jkss.2009.16.2.142

Abstract

Sagittal spinal balance is an essential factor for not only the external appearance, but also for the spine's function. Fixed sagittal imbalance is the result of different causes, and this generally requires surgical treatment. Sagittal imbalance is mainly caused by decreased lumbar lordosis and increased thoracic kyphosis, and it can also be influenced by the pelvic incidence and flexion contracture of the hip and knee joints. So, a careful understanding and clinically considering the many factors and compensatory mechanisms that are associated with sagittal imbalance are needed. Proper surgical treatments provide a satisfactory outcome for these patients and good radiographic results. Correction of sagittal imbalance generally requires spinal osteotomy and long segment fusion. For the surgical treatment, we should consider the perioperative and postoperative complications of osteotomy and long segment fusion and then make proper decisions for the range of fusion of the proximal and distal sides and the selection of the correct method of osteotomy, the ideal correction angle and the best method of internal fixation. Problems such as loss of correction may occur postoperatively due to kyphotic change and pseudarthrosis of the proximal and distal sides. Therefore, we need to conduct a thorough analysis and make a detailed plan for the surgical approach. We should also study and understand the radiological factors when treating sagittal spinal balance because not only the spine, but also the pelvis, hip and knee joints are involved in forming the sagittal balance

Keyword

Sagittal imbalance; Sagittal analysis; Sagittal correction

MeSH Terms

Animals
Contracture
Hip
Humans
Incidence
Knee Joint
Kyphosis
Lordosis
Osteotomy
Pelvis
Postoperative Complications
Pseudarthrosis
Spine

Figure

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  Fig. 1. Etiology of sagittal imbalance; lateral radiograph of a patient with Lumbar degenerative kyphosis (A), malaligned lumbar fusion (B), ankylosing spondylitis (C).

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  Fig. 2. The optimal patient position for obtaining a lateral 36” radiograph; the clavicle position fully flexes the elbows. The hands are placed in a relaxed fist, with the wrists flexed, and the PIP joints are placed into the supraclavicular fossae. There is no external support14).

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  Fig. 3. The pelvic parameters. Pelvic incidence: the angle between the perpendicular to the sacral plate at its midpoint and the line connecting this point to the middle axis of the femoral heads. Sacral slope: the angle between the superior plate of S1 and a horizontal line. Pelvic tilting: the angle between the line connecting the midpoint of the sacral plate to the axis of the femoral heads, and the vertical.

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  Fig. 4. Preoperative lateral (A, D) radiographs of patients with lumbar degenerative kyphosis. Note the severe sagittal imbalance on the lateral radiograph after a few minutes walking (B, E). Ideal lumbar lordosis -65。 and -72。 as the Legaye formula21) with 50。 and 63。 of pelvic incidence. Postoperative lateral radiographs following a pedicle substraction osteotomy at the L2 (C, F). Note the improved lumbar lordosis -65。, -75。 and sagittal balance (a change in the deviation of the sagittal vertical axis to negative value) compared with those seen on the preoperative radiographs.

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