Preliminary Results of Instantaneous Centre of Rotation Change after Thoracic Instrumentation in Adolescent Idiopathic Scoliosis Patients

@#Introduction: The instantaneous centre of rotation (ICR) is the centre of motion with zero velocity where a rigid body moves in a particular plane. ICR, as a dynamic measurement, gives more accurate results in terms of quality and quantity of the vertebral motions compared to range of motion (ROM). We aimed to determine the effect of thoracic instrumentation on cervical movement of adolescent idiopathic scoliosis (AIS) patients who had undergone thoracic level instrumentation by measuring pre-operative and post-operative ICR change in a pilot study Materials and methods: A total of 25 AIS patients were included in this study. C4-C5 and C6-C7 segmental ICR were determined by pre-operative and post-operative cervical flexion-extension radiographs. In addition, cervical sagittal parameters and global sagittal parameters were investigated. Results: There was no statistically significant change in ICR location post-operatively in both x and y coordinates at C4- C5 segment (p: 0.326 and p: 0.946, respectively) and C6-C7 segment (p: 0.209, p: 0.086, respectively). There was a positive correlation between LCL and C4-C5 ICR y coordinate (r: 0.481), but not with C6-C7 ICR y coordinate (r: -0.2, p: 0.398). T5-T12 kyphosis decreased (p: 0.002) and T1 pelvic angle (0.003), SVA (0.02) and sacral slope (0.049) increased significantly post-operatively. T1S was correlated with LCL (r: 0.595, p: 0.002), T5-T12 kyphosis (r: 0.423, p: 0.035), SVA (r: 0.658, p<0.001) and C2-C7 SVA (r: 0.416, p: 0.039). Conclusion: The ICR for cervical region was not changed post-operatively in AIS patients with thoracic instrumentation. There was no relationship found between the development of post-operative cervical kyphosis or lordosis and ICR, which represents the quality and quantity of intervertebral motion. The T1 vertebra plays a key role for cervical, thoracic, and global parameters interaction.

Significance of spinal sagittal balance for guiding acetabular prosthesis positioning / 中国骨伤

Since the concept of "safe area" put forward by Lewinnek, it has been widely recognized. While in recent years, many scholars have found that even if the acetabular prosthesis was placed on the "safe area", there were still many unexplained dislocation after total hip arthroplasty. And scholars began to question whether the "safe area" is really suitable for all patients. Spinal degeneration, deformity, lumbar fusion, etc. will lead to spine sagittal imbalance and changes in pelvic activity, which could lead to changes in acetabular orientation, and ultimately lead to edge loading, wear, impact, and even dislocation after total hip replacement. From the perspective of wear, impact and dislocation, it is determined by the functional positioning of the acetabular cup, not the anatomical positioning. The anatomical positioning and functional positioning of the neutral pelvic acetabular cup in the standing position can be considered equivalent. For pelvic rotation more than 20°, functional placement needs to be considered. In recent years, as the understanding of the internal relationship between the spine-pelvis-hip joint has become more and more profound, some scholars further classify the hip-spine relationship according to whether the spine is stiff or deformed, and propose corresponding acetabulums according to different types of hip-spine relationships The function of placement, so as to achieve a stable artificial hip joint. Therefore, it is of great significance to fully assess whether the patient's sagittal plane is balanced before surgery to guide artificial hip replacement surgery.

Influencia del balance sagital sobre los cambios degenerativos de la columna vertebral (I) / Influence of Sagittal Balance on Degenerative Changes in the Spine (I)

RESUMEN Los estudios han determinado la importancia del balance sagital en el desarrollo de entidades degenerativas de la columna vertebral, fundamentalmente de la región lumbar; así como en los resultados de las intervenciones quirúrgicas de estas afecciones. Es propósito de este trabajo revisar y discutir los conceptos actuales sobre la estabilidad sagital vertebral y lumbar, así como su influencia sobre el proceso degenerativo espinal, de manera fundamental sobre estenosis, espondilolistesis y escoliosis degenerativa. Existen parámetros pélvicos y parámetros espinales que tienen que tomarse en cuenta para la determinación preoperatoria y posoperatoria del equilibrio sagital. El equilibrio sagital se clasifica en: balance normal, balance compensado y desbalance. Esto tiene gran importancia para llegar al diagnóstico correcto y aplicar el tratamiento quirúrgico necesario(AU)

ABSTRACT Studies have determined the importance of sagittal balance in the development of degenerative entities of the spine, mainly in the lumbar region; as well as in the results of the surgical interventions of these affections. The purpose of this paper is to review and discuss current concepts on vertebral and lumbar sagittal stability, as well as its influence on the degenerative spinal process, basically on stenosis, spondylolisthesis and degenerative scoliosis. There are pelvic parameters and spinal parameters that have to be taken into account for the preoperative and postoperative determination of sagittal balance. Sagittal balance is classified into normal balance, compensated balance and imbalance. This is very important to reach the correct diagnosis and apply the necessary surgical treatment(AU)

Calidad de vida y balance sagital en la evolución de los pacientes con mieloma múltiple tratados con vertebroplastia percutánea / Quality of Life and Sagittal Balance in the Evolution of Patients with Multiple Myeloma Who Received Treatment

RESUMEN Introducción: El mieloma múltiple representa el 1 por ciento de las neoplasias y el 10 por ciento de las hemopatías malignas. La edad media de presentación es 65 años. El dolor óseo en columna vertebral y costillas constituye su manifestación inicial. El tratamiento quirúrgico del mieloma múltiple en la columna consiste en descompresión amplia y artrodesis. La vertebroplastia se considera técnica de elección porque restablece el balance sagital y coronal, contribuye al fortalecimiento del cuerpo vertebral, y disminuye el dolor asociado a fracturas. Objetivo: Evaluar el efecto de la vertebroplastia sobre la calidad de vida y el balance sagital, en la disminución del dolor. Métodos: Se estudiaron 192 pacientes con mieloma múltiple con fractura en la columna, 80 tratados con vertebroplastia y 112 en forma conservadora. Se utilizó el cuestionario de Oswestry y la escala de Karnosfky. Resultados: La vertebroplastia disminuyó 0,52 veces el uso de analgésicos opioides. Conclusiones: La vertebroplastia representa un mayor beneficio de la calidad de vida de los pacientes aquejados de mieloma múltiple con fractura vertebral; repercute en el mejoramiento del balance sagital, el nivel de discapacidad y la capacidad para realizar tareas cotidianas(AU)

ABSTRACT Introduction: Multiple myeloma accounts for 1 percent of neoplasms and for 10 percent of malignant hematomas. The mean onset age is 65 years. Bone pain in the spine and ribs is its initial manifestation. Surgical treatment for multiple myeloma in the spine consists in wide decompression and arthrodesis. Vertebroplasty is considered the choice technique because it restores sagittal and coronal balance, contributes to the strengthening of the vertebral body, and reduces pain associated with fractures. Objective: To assess the effect of vertebroplasty on quality of life and the effect of sagittal balance in reducing pain. Methods: 192 patients with multiple myeloma and spinal fracture were studied, 80 treated with vertebroplasty and 112 treated conservatively. The Oswestry questionnaire and the Karnofsky scale were used. Results: Vertebroplasty decreased the use of opioid analgesics by 0.52 times. Conclusions: Vertebroplasty represents a greater benefit for the quality of life of patients suffering from multiple myeloma with vertebral fracture. It affects the improvement of sagittal balance, the level of disability, and the ability to perform daily tasks(AU)

Correlation of parameters of lordosis type cervical spine saggitai plane in asymptomatic adults / 中国组织工程研究

BACKGROUND: Normal sagittal balance of cervical spine is the key to cervical spine orthopedic surgery. As the complexity of the anatomical structure and physiological function of the cervical spine, accurate measurement of sagittal balance parameters and correlation between parameters become an important reference for preoperative planning and postoperative evaluation of curative effect. Current research focuses on patients with clinical symptoms of cervical syondylosis. OBJECTIVE: To investigate the correlation of parameters of lordosis type cervical spine saggitai plane in asymptomatic adults. METHODS: Cervical anteroposterior and lateral DR images of 120 adult patients with asymptomatic lordosis type cervical spine were retrospectively analyzed. The subjects were divided into three groups according to age: Group A (21-40 years), group B (41-60 years), and group C (61-80 years). The sagittal parameters of the cervical spine were measured, including C2-C7 sagittal vertical axis (C2-C7SVA), central of gravity to C7 sagittal vertical axis (CG-C7 SVA), T1 slope, C0-C2 Cobb angle and C2-C7 Cobb angle. The correlation between different imaging parameters and age was analyzed. This study was approved by the Ethics Committee, First Hospital of Shijiazhuang and Second Hospital of Hebei Medical University. All subjects signed the informed consent. RESULTS AND CONCLUSION: (1) C2-C7 SVA (F=11.188, P < 0.001), CG-C7 SVA (F=6.132, P=0.003) and T, slope (F=11.682, P < 0.001) were significantly different among different groups. There was no significant difference in C0-C2 Cobb angle (F=1.178, P=0.311) and C2-C7 Cobb angle (F=0. 860, P=0. 426). (2) T1 slope was (51,63±5.85)°, (54.66±5.58)° and (57.48±4.74)° in groups A, B and C, respectively. Linear correlation analysis showed that T1 slope was positively correlated with age (r=0. 533, P < 0. 001). T1 slope was positively correlated with C2-C7 Cobb angle (r=0. 561, P< 0.001). These results indicated that T1 slope increased with age in asymptomatic cervical lordosis adults. Moreover, T1 slope was positively correlated with age.

Anatomía de las osteotomías dorsolumbares en fotografías en 3D / Anatomy of thoracolumbar osteotomies in 3D photographs

Introducción y objetivo: Existe evidencia contundente que demuestra la relación entre el balance sagital y la calidad de vida de los pacientes adultos con deformidad espinal, de manera que la corrección y realineación en ese plano se ha transformado en un objetivo primario en el tratamiento quirúrgico de dichas afecciones. Las osteotomías dorsolumbares permiten liberar el raquis para realizar dicha realineación sin el uso de fuerza indebida. Sin embargo, son técnicas complejas y con alta tasa de complicaciones intra y post operatorias. Teniendo en cuenta que el conocimiento anatómico de dichos procedimientos es clave, el objetivo de esta revisión consiste en realizar una descripción de las osteotomías dorsolumbares mediante el uso de fotografías en 3D de un preparado cadavérico de raquis lumbar. Materiales y métodos: Se utilizó un preparado cadavérico formolizado de raquis lumbar. Se realizaron las osteotomías espinales lumbares según la clasificación de Schwab et al., en los segmentos L3 y L4. Se tomaron imágenes fotográficas en 3 dimensiones utilizando equipo Nikon D90, con lente 50 mm Af 1.8G, flash Nikon SB700, y una barra regulable para fotografía 3D. Las imágenes fotográficas obtenidas fueron procesadas con los siguientes softwares con técnica anaglífica: Anaglyph Maker versión 1.08 y StereoPhoto Maker versión 4.54. Resultados: Se realiza una descripción de las osteotomías según la clasificación en 6 grados anatómicos de Schwab y colaboradores. Conclusión: La utilización de la técnica fotográfica 3D permitió demostrar el tipo y magnitud de resección ósea necesaria en cada grado de osteotomía.

Introduction and objective: There is strong evidence that shows the relationship between the sagittal balance and the quality of life of adult patients with spinal deformity. According to that, the correction and realignment of the sagittal plane has become a primary objective in the surgical treatment of these conditions. The dorsolumbar osteotomies allow the spine to be released, in order to perform that realignment without the use of undue force. However, they are complex techniques, with a high rate of intra and post-operative complications. Taking into account that the anatomical knowledge of these procedures is fundamental, the objective of this review was to describe the dorsolumbar osteotomies using 3D photographs of a cadaveric preparation of the lumbar spine. Materials and methods: A cadaveric formolized lumbar spine preparation was used. Lumbar spinal osteotomies were performed according to the classification of Schwab et al. Three-dimensional photographic images were taken using Nikon D90 equipment, with a 50mm AF 1.8G lens, Nikon SB700 flash, and an adjustable bar for 3D photography. The photographic images obtained were processed with the following software with anaglyphic technique: Anaglyph Maker version 1.08 and StereoPhoto Maker version 4.54. Results: A description of the osteotomies was made, according to the 6 anatomic grades classification developed by Schwab et al. Conclusion: The use of the 3D photographic technique allowed to demonstrate the type and magnitude of bone resection needed in each degree of osteotomy.

Analysis of spinopelvic sagittal parameters in degenerative lumbar spondylolisthesis / 第二军医大学学报

Objective To explore the characteristics of spinopelvic sagittal parameters in degenerative lumbar spondylolisthesis patients and the relationship between these parameters and lumbar spondylolisthesis. Methods From Jun. 2016 to Jun. 2018, 42 patients with degenerative lumbar spondylolisthesis (DLS) were enrolled in study group, and 58 degenerative lumbar disease patients without spondylolisthesis were enrolled in control group. The general characteristics of the patients were collected. The sagittal parameters, including pelvic tilt (PT), pelvic incidence (PI), sacral slope (SS), thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), lumbar lordosis (LL) and sagittal vertical axis (SVA), were measured on lateral X-ray films of full-length spine. The differences of general characteristics and sagittal parameters were compared between the two groups. With the lumbar spondylolisthesis rate as dependent variable and the spinopelvic sagittal parameter as independent variable, logistic regression model was used to analyze the risk factors of lumbar spondylolisthesis. Results There were no significant differences in the age, gender, height or body mass of the patients between the two groups (all P>0.05). There were significant differences in the PT, PI, SS, LL, TLK and SVA between the DLS group and the control group (all P0.05). Logistic regression analysis showed that LL and PT were risk factors of lumbar spondylolisthesis (both P<0.05). Conclusion The sagittal parameters (PT, PI, SS, LL, TLK and SVA) in the patients with DLS are significantly changed. LL and PT are the risk factors of lumbar spondylolisthesis.

Effect of anterior cervical discectomy and decompression with different fusion segments on sagittal spine-pelvis balance / 中国修复重建外科杂志

Objective: To explore the effect on sagittal spine-pelvis balance of different fusion segments in anterior cervical discectomy and fusion (ACDF). Methods: The clinical data of 326 patients with cervical spondylotic myelopathy, treated by ACDF between January 2010 and December 2016, was retrospectively analysed. There were 175 males and 151 females with an average age of 56 years (range, 34-81 years). Fusion segments included single segment in 69 cases, double segments in 85 cases, three segments in 90 cases, and four segments in 82 cases. Full spine anterolateral X-ray films were performed before operationand at 12 months after operation. The spine-pelvis parameters of fusion segments were measured and compared. The parameters included C 0-2 Cobb angle, C 2-7 Cobb angle, C 2-7 sagittal vertical axis (C 2-7 SVA), T 1 slope (T 1S), thoracic inlet angle (TIA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), C 7 sagittal vertical axis (C 7 SVA), T 1 pelvic angle (TPA). The Japanese Orthopaedic Association (JOA) score of cervical spine and visual analogue scale (VAS) scores of pain of cervical spine and upper extremity were compared before operation and at 12 months after operation. Pearson correlation analysis was performed on LL, PI, SS, C 7 SVA, and TPA before and after operation to evaluate the changes of spine-pelvis fitting relationship after ACDF. Results: All 326 patients were followed up 12-32 months (mean, 18.5 months). During the follow-up period, internal fixator was in place, and no spinal cord nerve or peripheral soft tissue injury was found. JOA scores and cervical VAS scores improved significantly at 12 months after operation ( P0.05). The preoperative cervical VAS scores and the postoperative JOA scores at 12 months had significant differences between groups ( P0.05); but the C 0-2 Cobb angle, C 2-7 Cobb angle, C 2-7 SVA, T 1S, TIA, C 7 SVA, and TPA in the double segments, three segments, and four segments groups were significant larger than preoperative ones ( P<0.05). The C 0-2 Cobb angle, C 2-7 Cobb angle, T 1S, C 7 SVA, and TPA among 4 groups had significant differences before operation and at 12 months after operation ( P<0.05). At 12 months after operation, the changes of C 7 SVA and TPA in the double segments, three segments, and four segments groups were significantly larger than those in the single segment group ( P<0.05). PI had positive correlations with LL and SS before and after operation in 4 groups ( P<0.05). Conclusion: Normal fitting relationship between lumbar spine and pelvis in physiological state also exists in patients with cervical spondylotic myelopathy, and ACDF can not change this specific relationship. In patients with cervical spondylotic myelopathy, the sagittal spine-pelvis sequence do not change after ACDF single-level fusion, while the sagittal spine-pelvis balance change after double-level and multi-level fusion.

Sagittal Balance Correction Following Lumbar Interbody Fusion: A Comparison of the Three Approaches

STUDY DESIGN: Retrospective cohort study. PURPOSE: The objective of this study was to compare three widely used interbody fusion approaches in regard to their ability to correct sagittal balance, including pelvic parameters. OVERVIEW OF LITERATURE: Restoration of sagittal balance in lumbar spine surgery is associated with better postoperative outcomes. Various interbody fusion techniques can help to correct sagittal balance, with no clear consensus on which technique offers the best correction. METHODS: The charts and imaging of patients who have undergone surgery through either open transforaminal lumbar interbody fusion (TLIF), minimally invasive TLIF (MIS TLIF), or oblique lumbar interbody fusion (OLIF) were retrospectively reviewed. The following sagittal balance parameters were measured pre- and postoperatively: segmental lordosis, lumbar lordosis, disk height, pelvic tilt, and pelvic incidence. Data on postoperative complications were gathered. RESULTS: Only OLIF managed to significantly improve segmental lordosis (4.4°, p<0.001) and lumbar lordosis (4.8°, p=0.049). All approaches significantly augmented disk height, with OLIF having the greatest effect (3.7°, p<0.001). No approaches were shown to significantly correct pelvic tilt. Pelvic incidence remained unchanged in all approaches. Open TLIF was the only approach with a higher rate of postoperative complications (33%, p=0.009). CONCLUSIONS: The OLIF approach might offer greater correction of sagittal balance over open and MIS TLIF, mainly in regard to segmental lordosis, lumbar lordosis, and disk height. MIS TLIF, although offering more limited access than open TLIF, was not inferior to open TLIF in regard to sagittal balance correction. A higher rate of complications was shown for open TLIF than the other approaches, possibly due to its more invasive nature.

Prediction of risk factors of occurrence and development of degenerative lumbar spondylolisthesis with sagittal parameters of the spine and pelvis / 临床外科杂志

Objective To explore the risk factors related to the development and progression of lumbar degenerative spondylolisthesis (LDS).Methods A total of 71 patients with LDS or degenerative spinal stenosis (DSS) were retrospectively.Thirty-six patients with LDS (group LDS) and 35 patients with DSS (group DSS) were enrolled.Spinopelvic parameters including pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), thoracic kyphosis (TK), regional lumbopelvic lordosis angles (PR-LI, PR-L2, PR-L3, PR-L4, PR-L5), pelvic morphology (PR-S1), lumbar 4 slope (L4 S) and lumbar 5 slope (L5 S) were assessed on whole spine lateral radiographs in a standing position.All the parameters from LDS will compared with those of DSS and normal population respectively, Student's t-test was used to compare each parameter among the LDS, DSS and normal population.Results PI [ (57.67±11.78) °], SS [ (37.83±9.17) °] and LL [ (54.65±11.45) °] in group LDS were significantly greater than those of group DSS [ (44.47±8.75) °, (28.18±9.02) °, (38.97±15.59) °] and normal reference value [ (44.75±9.01) °, (33.57±7.64) °, (48.75±10.03) °] (P＜0.05).L4 S [ (8.18±9.98) °] and L5 S [ (19.96±8.33) °] in group LDS were greater than the group DSS[ (3.32±7.95) °, (10.87±8.02) °] (P＜0.05).The PR-L4 [ (57.63±13.44) °], PR-L5 [ (45.76±10.92) °] and PR-S1 [ (27.91±10.41) °] in group LDS were significantly smaller than those of group DSS [ (65.48±10.70) °, (56.33±9.15) °, (38.63±7.29) °] (P＜0.05).Conclusion Greater PI may lead to the development and progression of lumbar degenerative spondylolisthesis.L5 S is a parameter that can be used to predict the risk of LDS.The lower regional lumbopelvic lordosis angles in LDS were smaller than those of DSS.

Radiological analysis of coronal and sagittal spinopelvic parameters in patients with degenerative lumbar kyphoscoliosis / 中华外科杂志

Objective@#To review and compare radiological parameters between degenerative lumbar kyphoscoliosis (DLKS) and degenerative lumbar kyphosis (DLK), and analyze the relationships between coronal and sagittal deformities and compensatory mechanisms of sagittal balance.@*Methods@#A total of 82 patients with lumbar degenerative deformities were enrolled for our radiographic study at Department of Spinal Surgery, Peking University People′s Hospital from January 2016 to May 2017. These patients were divided into two groups: DLKS group (39 patients) with lumbar coronal and sagittal deformities, and DLK group (43 patients) just with lumbar sagittal deformity. Complete spinopelvic radiographic parameters were compared.@*Results@#The Cobb angle and lumbar lordosis of DLKS group were (23.0±11.8)° and (18.2±12.1)°, while the lumbar lordosis of DLK group was (20.4±10.2)°. In DLKS group, Cobb angle had correlations with lumbar lordosis(r=-0.338, P=0.035), and central sacral vertical line distance had significant correlations with thoracolumbar junctional angle (r=0.488, P=0.002) . Moreover, no significant differences of all sagittal spinopelvic parameters were found between two groups (P>0.05). In DLKS group, significant correlations between lumbar lordosis and sacral slope (r=0.617, P=0.000), and correlations between lumbar lordosis and thoracic kyphosis(r=-0.363, P=0.023) were observed. In DLK group, lumbar lordosis showed significant correlations with thoracic kyphosis(r=-0.341, P=0.025) and sacral slope (r=0.772, P=0.000). According to Nash-Moe grading scale of apical vertebral rotation, 10 patients were with Ⅰ-Ⅱ grade while 29 patients with Ⅲ-Ⅴ grade in DLKS group.@*Conclusions@#Both as typical lumbar degenerative deformities, there are some correlations between scoliosis and kyphosis. However, coronal scoliosis may not influent sagittal morphological parameters for DLKS patients. Thoracic curve changes and pelvic backtilt are both important for maintaining the sagittal balance in patients with degenerative lumbar kyphoscoliosis.

Correlation between spinal sagittal balance and quality of life after treatment of percutaneous kyphoplasty in osteoporotic vertebral compressive fracture / 实用医学杂志

Objective To explore the correlation between spinal sagittal balance and quality of life after the treatment of percutaneous kyphoplasty in osteoporotic vertebral compressive fractures. Methods We retrospec-tively enrolled and screened 85 patients with osteoporotic vertebral compression fractures(OVCF),treated by per-cutaneous kyphoplasty(PKP)in spinal surgery department of Shanghai East Hospital from January 2012 to Decem-ber 2016. The full length of the spine X-ray examinations had been taken preoperatively,pre-discharge and during the follow-up and spine-pelvis sagittal parameters included C7 sagittal vertical axis(C7SVA),thoracic kyphosis (TK),lumber lordosis(LL),pelvic incidence(PT)and sacral slope(SS). Shot Form 36 Health Survey Question-naire(SF-36)was used for the scoring. Results In the last follow-up,C7SVA decreased from(35.9 ± 17.1)mm to(30.8 ± 12.8)mm(P=0.002)and SF-36 scores varied significantly(P<0.01). Before the surgery,follow-up 3 days,6 months and 12 months after the surgery,C7SVA was negatively correlated with the general health status in each period of SF-36(r=-0.343,-0.264,-0.272,-0.258;P=0.001,0.015,0.012,0.017). Conclusions PKP has a significant effect on OVCFs and changes the spine-pelvic sagittal balance in patients with OVCF. Spinal-pel-vic sagittal balance is closely related to the quality of life of these patients.

The effect of spinal sagittal balance on secondary fracture after percutaneous kyphoplasty for osteoporotic vertebral compression fractures / 中华创伤骨科杂志

Objective To explore the effect of spinal sagittal balance on secondary vertebral fracture after percutaneous kyphoplasty (PKP) for osteoporotic vertebral compression fractures (OVCF).Methods The data were reviewed of the patients with single segmental OVCF who had undergone PKP at Department of Spine Surgery,Second Hospital of Lanzhou University from March 2014 to December 2015.Of them,21 had secondary vertebral fracture after PKP.As an observational group,they were matched with another 21 patients without secondary vertebral fracture after PKP as a control group (ratio:1:1) for age,gender,body mass index (BMI) and bone mineral density (BMD).Their standard standing plain radiographs of the whole spine were used to measure the parameters of spine-pelvis sagittal balance.The 2 groups were compared in sagittal balance parameters.Results The sagittal vertical axis (26.86 ± 33.55 mm) and thoracic kyphosis (47.62° ± 10.73°) in the observational group were significantly larger than those (4.05 ± 31.93 mm and 41.10 °±8.17°) in the control group (P ＜0.05);the lumbar lordosis (35.29°±8.77 °),sacral slope (22.71 ° ± 5.80°) and pelvic incidence (45.38° ± 7.49°) in the former were significantly smaller than those in the control group (41.71°±9.19°,27.43°±5.29° and 51.19°±8.44°) (P ＜0.05);there were no significant differences between the 2 groups in pelvic tilt or thoracolumbar kyphosis (P ＞ 0.05).Conclusions The OVCF patients with larger sagittal vertical axis,larger thoracic kyphosis and smaller lumbar lordosis may be more likely to suffer secondary vertebral fracture after PKP.A larger pelvic incidence may be a protective factor against secondary vertebral fracture after PKP for OVCF patients.

Spinal Deformity Surgery: A Critical Review of Alignment and Balance

Correction of the overall coronal and/or sagittal plane deformities is one of the main predictors of successful spinal surgery. In routine clinical practice, spinal alignment is assessed using several spinal and pelvic parameters, such as pelvic incidence and tilt, sacral slope, lumbar lordosis, thoracic kyphosis, and sagittal vertical axis. Standard values have been defined for all these parameters, and the formulas of correction have been set for determining the surgical strategy. However, several factors can potentially bias these formulas. First, all standard values are measured using conventional plain radiographs and are, therefore, prone to bias. The radiologist, measuring surgeon, and patient are possible confounding influencing factors. Second, spino-pelvic compensatory effects and biomechanically relevant structures for the patient’s posture, including ligaments, tendons, and muscles, have received minimal consideration in the literature. Therefore, even in cases of appropriately planned deformity correction surgeries, complications, revision rates, and surgical outcomes significantly vary. This study aimed to illustrate the current clinical weaknesses of the assessment of spinal alignment and the importance of holistically approaching the musculoskeletal system for any spinal deformity surgery. We believe that our detailed insights regarding spinal, sagittal, and coronal alignments as well as the considerations of an individual's spinal balance will contribute toward improvement in routine patient care.

A Comparative Study of Sagittal Balance in Patients with Neuromuscular Scoliosis

OBJECTIVES: Spinopelvic alignment has been associated with improved quality of life in patients with vertebral deformities, and it helps to compensate for imbalances in gait. Although surgical treatment of scoliosis in patients with neuromuscular spinal deformities promotes correction of coronal scoliotic deformities, it remains poorly established whether this results in large changes in sagittal balance parameters in this specific population. The objective of this study is to compare these parameters before and after the current procedure under the hypothesis is that there is no significant modification. METHODS: Sampling included all records of patients with neuromuscular scoliosis with adequate radiographic records treated at Institute of Orthopedics and Traumatology of Clinics Hospital of University of São Paulo (IOT-HCFMUSP) from January 2009 to December 2013. Parameters analyzed were incidence, sacral inclination, pelvic tilt, lumbar lordosis, thoracic kyphosis, spinosacral angle, spinal inclination and spinopelvic inclination obtained using the iSite-Philips digital display system with Surgimap and a validated method for digital measurements of scoliosis radiographs. Comparison between the pre- and post-operative conditions involved means and standard deviations and the t-test. RESULTS: Based on 101 medical records only, 16 patients met the inclusion criteria for this study, including 7 males and 9 females, with an age range of 9-20 and a mean age of 12.9±3.06; 14 were diagnosed with cerebral palsy. No significant differences were found between pre and postoperative parameters. CONCLUSIONS: Despite correction of coronal scoliotic deformity in patients with neuromuscular deformities, there were no changes in spinopelvic alignment parameters in the group studied.

Effect of Sagittal Balance on Risk of Falling after Lateral Lumbar Interbody Fusion Surgery Combined with Posterior Surgery

PURPOSE: To demonstrate the impact of correcting sagittal balance (SB) on functional outcomes of surgical treatment for degenerative spinal disease and actual falls via utilization of new minimally invasive lumbar fusion techniques via a lateral approach. MATERIALS AND METHODS: From November 2011 to March 2015, we enrolled 56 patients who underwent minimally invasive lateral lumbar interbody fusion (LLIF) and matched 112 patients receiving decompression/postero-lateral fusion (PLF) surgery for lumbar spinal stenosis. According to SB status using C7-plumb line-distance (C7PL) and surgery type, patients were divided into three groups: SB PLF, sagittal imbalance (SI) PLF, and LLIF groups. We then compared their outcomes. RESULTS: The mean C7PL was 6.2±13.6 mm in the SB PLF group, 72.9±33.8 mm in the SI PLF group, and 74.8±38.2 mm in the LLIF group preoperatively. Postoperatively, C7PL in only the LLIF group improved significantly (p=0.000). Patients in the LLIF group showed greater improvement in fall-related functional test scores than the SI PLF group (p=0.007 for Alternate-Step test, p=0.032 for Sit-to-Stand test). The average number of postoperative falls was 0.4±0.7 in the SB PLF group, 1.1±1.4 in the SI PLF group, and 0.8±1.0 in the LLIF group (p=0.041). Oswestry Disability Index and the Euro-QoL 5 dimension visual analogue scale scores also showed greater improvements in the LLIF group than in the SI PLF group at postoperative 1 year (p=0.003, 0.016). CONCLUSION: Surgical correction of SI in patients with lumbar spinal stenosis using a combination of minimal invasive LLIF and posterior surgery achieved better surgical outcomes and a lower incidence of actual falls than PLF surgery.

Global balance in adult spinal deformities. A study of 60 cases / Alinhamento global em deformidades da coluna vertebral do adulto. Um estudo de 60 casos / Balance global en las deformidades espinales del adulto. Un estudio de 60 casos

ABSTRACT Objectives: Determine the most prevalent type of curve in our population, to quantify the radiographic parameters such as PT, IP, SS and compare the physical function according to ODI and SRS-22r. Methods: Retrospective, observational, longitudinal, single-center study, carried out from January 2010 to May 2015 at the Centro Médico ISSEMYM Ecatepec, Spine Surgery Service. Results: A total of 60 patients were obtained, 60% female, with curvatures according to SRS-Schwab, type T (28%), TL (46.6%), D (15%), N (10%), with a mean preoperative VAS of 7 for all curves and post-surgical 2 after 6 months. The SRS-22r preoperative test was 2.1 and postoperatively was 3.75, with p<0.001. Conclusions: Deformities of the adult spine are a growing disease in our country. The surgical management of deformities requires proper clinical and radiographic planning. Patients undergoing surgical treatment in our study showed curvature type TL and demonstrated significant improvement in ODI and SRS-22r.

RESUMO Objetivos: Determinar o tipo de curva mais prevalente em nossa população, quantificar os parâmetros radiográficos, tais como PT, PI, SS e comparar a função física de acordo com ODI e SRS-22r. Métodos: Estudo retrospectivo, observacional, longitudinal, em centro único, realizado no período de janeiro de 2010 a maio de 2015 no Centro Médico ISSEMYM Ecatepec, Serviço de Cirurgia da Coluna. Resultados: Reuniu-se um total de 60 pacientes, 60% do sexo feminino, com curvaturas, de acordo com o SRS-Schwab, tipo T (28%), TL (46,6%), D (15%), N (10%), com EVA média pré-operatória de 7 para todas as curvas e pós-cirúrgica de 2 depois de 6 meses. O teste SRS-22r pré-operatório foi de 2,1 e o pós-operatório foi de 3,75, com p < 0,001. Conclusões: As deformidades da coluna vertebral do adulto são uma doença crescente em nosso país. O tratamento cirúrgico das deformidades requer planejamento clínico-radiográfico adequado. Os pacientes submetidos ao tratamento cirúrgico em nosso estudo mostraram curvatura tipo TL e apresentaram melhora significativa de ODI e SRS-22r.

RESUMEN Objetivos: Determinar el tipo de curva más frecuente en nuestra población, cuantificar los parámetros radiográficos como PT, PI, SS y comparar la función física de acuerdo al test de ODI y SRS-22r. Métodos: Estudio retrospectivo, observacional, longitudinal y unicéntrico, realizado en el periodo entre Enero de 2010 y Mayo de 2015 en el Centro Médico ISSEMYM Ecatepec, Servicio de Cirugía de Columna. Resultados: Se obtuvieron un total de 60 pacientes, 60% mujeres, con curvaturas, de acuerdo a la clasificación SRS-Schwab, tipo T (28%), tipo TL (46,6%), tipo D (15%), tipo N (10%), con una EVA prequirúrgica promedio de 7 para todo tipo de curvas y posquirúrgica de 2 a los 6 meses. El test de SRS-22r prequirúrgico fue de 2,1 y el posquirúrgico de 3,75 con p < 0,001. Conclusiones: Las deformidades espinales del adulto son una patología creciente en nuestro país. El manejo quirúrgico de las deformidades requiere una adecuada planeación clínico-radiográfica. Los pacientes sometidos a tratamiento quirúrgico en nuestro estudio mostraron una curvatura tipo TL y presentaron mejoría significativa del ODI y del SRS-22r.

Spino-Pelvic Parameters in Adult Spinal Deformities / 대한정형외과학회잡지

In the recent 10 to 15 years, the most popular issue in the spine field is evaluation and treatment of the sagittal alignment and sagittal balance of the spine. Adult spine deformity (ASD) includes not only coronal deformity, such as degenerative scoliosis, but also sagittal deformity. Degenerative scoliosis is also associated with sagittal deformity of the spine. Even in degenerative scoliosis, accompanying sagittal deformity is more important to clinical symptoms than coronal deformity. Sagittal deformity of the spine is significantly correlated with health-related quality of life score, such as visual analogue scale and Oswestry disability index, short form-36 health survey. For the appropriate evaluation and treatment of ASD, understanding the normal and abnormal sagittal alignment and sagittal balance of the spine is very important. Various compensatory mechanisms should be applied in order to maintain the balanced upright posture. Assessment of the compensatory mechanism is also mandatory for proper surgical planning. Some spinopelvic parameters show particularly high correlation with clinical symptoms in case of sagittal imbalance. Therefore, assessment of these parameters is necessary for evaluation of surgical outcomes.

Sagittal Pelvic Radius in Low-Grade Isthmic Lumbar Spondylolisthesis of Chinese Population

OBJECTIVE: To investigate the variation of pelvic radius and related parameters in low-grade isthmic lumbar spondylolisthesis. METHODS: Seventy-four patients with isthmic lumbar spondylolisthesis and 47 controls were included in this study. There were 17 males and 57 females between 30 and 66 years of age, including 30 with grade I slippages and 44 grade II slippages; diseased levels included 34 cases on L4 and 40 cases on L5. Thoracic kyphosis (TK), the pelvic radius (PR), the pelvic angle (PA), pelvic morphology (PR-S1), and total lumbopelvic lordosis (PR-T12) were assessed from radiographs. RESULTS: Statistically significant differences were found for the PA, PR-T12, and PR-S1 (24.5±6.6°, 83.7±9.8°, and 25.4±11.2°, respectively) of the patients with spondylolisthesis and the healthy volunteers (13.7±7.8°, 92.9±9.2°, and 40.7±8.9°, respectively). The TK/PR-T12 ratios were between 0.15 and 0.75. However, there were no differences in all the parameters between the L4 and L5 spondylolysis subgroups (p>0.05). The TK and PR-S1 of grade II were less than grade I, but the PA was greater. The PR-T12 of female patients were less than male patients, but the PA was greater (p<0.05). CONCLUSION: Pelvic morphology differed in patients with low-grade isthmic lumbar spondylolisthesis compared to controls. Gender and the grade of slippage impacted the sagittal configuration of the pelvis, but the segment of the vertebral slip did not. Overall, the spine of those with spondylolisthesis remains able to maintain sagittal balance despite abnormal pelvic morphology.

Mini-Open Anterior Lumbar Interbody Fusion Combined with Lateral Lumbar Interbody Fusion in Corrective Surgery for Adult Spinal Deformity

STUDY DESIGN: Prospective observational study. PURPOSE: To introduce the techniques and present the surgical outcomes of mini-open anterior lumbar interbody fusion (ALIF) at the most caudal segments of the spine combined with lateral lumbar interbody fusion (LLIF) for the correction of adult spinal deformity OVERVIEW OF LITERATURE: Although LLIF is increasingly used to correct adult spinal deformity, the correction of sagittal plane deformity with LLIF alone is reportedly suboptimal. METHODS: Thirty-two consecutive patients with adult spinal deformity underwent LLIF combined with mini-open ALIF at the L5–S1 or L4–S1 levels followed by 2-stage posterior fixation. ALIF was performed for a mean 1.3 levels and LLIF for a mean 2.7 levels. Then, percutaneous fixation was performed in 11 patients (percutaneous group), open correction with facetectomy with or without laminectomy in 16 (open group), and additional pedicle subtraction osteotomy (PSO) in 5 (PSO group). Spinopelvic parameters were compared preoperatively and postoperatively. Hospitalization data and clinical outcomes were recorded. RESULTS: No major medical complications developed, and clinical outcomes improved postoperatively in all groups. The mean postoperative segmental lordosis was greater after ALIF (17.5°±5.5°) than after LLIF (8.1°±5.3°, p <0.001). Four patients (12.5%) had lumbar lordosis with a pelvic incidence of ±9° preoperatively, whereas this outcome was achieved postoperatively in 30 patients (93.8%). The total increase in lumbar lordosis was 14.7° in the percutaneous group, 35.3° in the open group, and 57.0° in the PSO group. The ranges of potential lumbar lordosis increase were estimated as 4°–25°, 23°–42°, and 45°–65°, respectively. CONCLUSIONS: Mini-open ALIF combined with LLIF followed by posterior fixation may be a feasible technique for achieving optimal sagittal balance and reducing the necessity of more extensive surgery.