Observations on Sagittal Alignment of Lumbo-Sacral Spine in Asymptomatic Adults in Kashmir

Introduction: Sacropelvic parameters in various spine and hipdisorders have been published in various studies. We aimed tostudy the normal sacropelvic parameters and curvatures of thespine and their correlation in asymptomatic Indian adults inrelation to variations in sex and age.Material and Methods: 200 Volunteers were taken fromgeneral population with age ranging from 18-50. Patientwas made to stand and left lateral radiograph exposing C7 toS1 and both the hips with a long 30x90 cm cassette placedat 230 cm from the X-ray tube was performed by a singleradiographer to avoid bias.Results: The average LL, SS, PI, PT, and SVA values wereaverage 55.61±10.68, 38.38±8.33,47.94±10.24,10.16±6.23 and 17.27±9.72 respectively. No statistically significantdifference was observed in statistical values with regardsto sex. Our study showed that PI has significant positivecorrelations with SS, LL and PT, and also affects LL. SS hassignificant positive correlation with LL.Conclusion: The current results could contribute to not onlythe understanding of normal sagittal spinal alignment, but alsoserve as a basis for realignment strategies in young Kashmiriadults.

Hypertension Is Related to Positive Global Sagittal Alignment: A Cross-Sectional Cohort Study

STUDY DESIGN: Cross-sectional cohort study.PURPOSE: This study aimed to investigate the relationship between hypertension and spino-pelvic sagittal alignment in middle-aged and elderly individuals.OVERVIEW OF LITERATURE: Positive global sagittal alignment is associated with poor health-related quality of life. Hypertension is associated with tissue microcirculation disorders of the skeletal muscle. We hypothesized that hypertension may be involved in positive global sagittal alignment.METHODS: In this institutional review board-approved study, 655 participants (262 men and 393 women; mean age, 72.9 years; range, 50–92 years) who underwent musculoskeletal screening in Toei town, Aichi, Japan were included. Whole spine and pelvic radiographs were taken, and radiographic parameters (thoracic kyphosis, lumbar lordosis, pelvic tilt, sacral slope, pelvic incidence, and sagittal vertical axis [SVA]) were measured using an image-analysis software. Hypertension was assessed using the standard criteria. The study participants were divided into three subgroups as per age (50–64 years, 65–74 years, and ≥75 years). We examined the differences in the radiographic parameters of those with and without hypertension in each age subgroup.RESULTS: In each age subgroup, there was no significant difference in the age and sex of those with and without hypertension. SVA was significantly shifted forward in the hypertension group than in the non-hypertension group in those aged 50–64 years old (32.4 mm vs. 16.0 mm, p=0.018) and in those aged 65–74 years old (42.7 mm vs. 30.6 mm, p=0.012). There was no significant difference between the hypertension and non-hypertension groups in terms of the alignment of the lumbar and thoracic spine in all the subgroups. In multivariate analysis, hypertension was a significant independent factor of forward-shifted SVA (standardized beta 0.093, p=0.015).CONCLUSIONS: This study showed that hypertension was associated with forward-shifted global sagittal alignment.

Novel Measurement Technique for the Sagittal Vertical Axis and Its Clinical Application in Adult Spinal Deformity

STUDY DESIGN: Prospective physical measurement of the sagittal vertical axis (SVA). PURPOSE: To evaluate a simple method for measuring SVA by analyzing its relationship with radiographic measurements and clinical appearance. OVERVIEW OF LITERATURE: No studies have examined physical measurements using the cranial center of gravity (CCG) in a relaxed standing position. METHODS: The physical measurement of the horizontal distance between CCG and spina iliaca posterior superior (CCG-SIPS) was measured using a straight ruler in 252 healthy volunteers and 56 patients with adult spinal deformity. Health-related quality of life (HRQOL) was evaluated using the Oswestry disability index (ODI), and clinical symptoms were assessed according to standing status and the presence of gastroesophageal reflux disease (GERD). RESULTS: CCG-SIPS increased with age in the volunteer group and strongly correlated with radiographic SVA in the patient group (r=0.984). Differences increased between CCG-SIPS in patients in the relaxed position and radiographic SVA with an increase in sagittal malalignment (r=0.692, p120 mm) was significantly larger in the patient group than in the group with low sagittal malalignment (59.9±18.8 vs. 45.1±17.0; p=0.004); these patients (CCG-SIPS>120 mm) needed crutches or walkers for standing. The patient group with GERD had significantly larger sagittal malalignment than the group without GERD (160.3 mm vs. 81.0 mm). CONCLUSIONS: The CCG-SIPS correlated with age and strongly reflected radiographic SVA and HRQOL in the patients. Moreover, it reflects a relaxed posture without a backward shift in the radiographic position even in patients with severe sagittal malalignment. The critical limit of CCG-SIPS can be relevant to clinical appearance, including standing assistance (>120 mm) and the existence of GERD (>150 mm). Thus, it will be a useful predictor of true SVA in clinical practice before radiographic evaluation.

Basic Pelvic Parameters Associated with Lumbar Degenerative Disease: Review Article

STUDY DESIGN: Literature review. OBJECTIVES: The aim of this study was to present updated information on the basic pelvic parameters associated with lumbar degenerative disease. SUMMARY OF LITERATURE REVIEW: Sagittal imbalance has been known to be related to a poor prognosis in almost all adult spine problems, including lumbar degenerative disease. MATERIALS AND METHODS: Review of the relevant literature. RESULTS: Pelvic incidence is a morphologic parameter of the pelvis. It influences lumbar lordosis and thoracic kyphosis, and determines the limitations of pelvic retroversion in sagittal imbalance. Pelvic tilt is a positional parameter of the pelvis, indicating the degree of compensation for sagittal imbalance. A C7-sagittal vertical axis >5 cm, pelvic tilt >20°, and pelvic incidence-lumbar lordosis mismatch are known to be independent factors predictive of poor outcomes. CONCLUSIONS: The C7-sagittal vertical axis, pelvic tilt, and pelvic incidence-lumbar lordosis mismatch should be considered when surgery is planned for a patient with degenerative lumbar disease.

Clinical Implications of Spino-pelvic Parameters for the Outcome of Spinal Surgery for Lumbar Degenerative Diseases

STUDY DESIGN: A review of the literature. OBJECTIVES: To discuss how to evaluate, interpret, and utilize measurements of spino-pelvic alignment before and after spinal surgery in patients with lumbar degenerative disease. SUMMARY OF LITERATURE REVIEW: Various spino-pelvic parameters are currently utilized in the evaluation of spinal patients; however, interpretation of these parameters is not easy. MATERIALS AND METHODS: Each spino-pelvic parameter and factors affecting its value, and how to interpret and utilize the spino-pelvic parameters before and after spinal surgery were discussed for patients with lumbar degenerative disease with and without sagittal spinal deformity. RESULTS: Sagittal modifiers in the SRS-Schwab classification including pelvic incidence minus lumbar lordosis (PI-LL), sagittal vertical axis (SVA), and pelvic tilt (PT) are widely accepted in the evaluation of lumbar degenerative disease with sagittal deformity. Surgery for sagittal realignment is meant to restore both the SVA and PT by restoring the LL in reference to the PI. However, patients with an extremely high SVA and PT or those with a high SVA and low PT can end up with postoperative residual malalignment. In patients without deformity, PI-LL mismatch (> 10°) should be highlighted and should be actively corrected by restoring the lordosis of the pathologic segment. CONCLUSIONS: Sagittal modifiers are beneficial for their simplicity and comprehensibility; however, they are insufficient for evaluating sub-regional spinal deformity. Spino-pelvic parameters can be useful for evaluating spinal patients in a clinical setting, but the measurements are greatly affected by confounding factors such as poor patient posture, unqualified testers, and manual measurement techniques.

Kyphotic Neck and Correlation With Clinical Outcomes

STUDY DESIGN: A literature review regarding the correlation between a kyphotic neck and its clinical outcomes. OBJECTIVES: This review examines normal cervical alignment, methods for assessing alignment, a specific correlation between kyphotic neck and clinical outcomes, and indications and methods of surgical treatment. SUMMARY OF LITERATURE REVIEW: Cervical kyphotic deformity is problematic in terms of HRQOL due to nerve damage or loss of horizontal gaze. MATERIALS AND METHODS: Review of the literature. RESULTS: Cervical kyphosis can be caused by postlaminectomy, degenerative disc disease, and trauma, and the symptoms exhibit diverse clinical progression including compensatory mechanisms, adjacent segment disease, changes in quality of life, and cervical myelopathy. Given the serious complications of cervical surgery, we need a deep understanding of spine anatomy, preoperative planning, and correction methods. CONCLUSIONS: It is vital to investigate cervical sagittal alignment and to perform intensive treatment and corrective surgery to achieve better clinical outcomes.

Analysis of Osteoporotic Spinal Compression Fractures in Whole Spine Sagittal MR Images

OBJECTIVES: To analyze the fracture type and adjacency of accompanied fractures in acute osteoporotic spinal compression fracture using whole spine sagittal MRI (WS-MRI), and to know the relation of sagittal vertical axis (SVA), body mass index (BMI), and lumbar bone mineral density (BMD). METHODS: From June 2007 to December 2010, 167 patients who had acute spinal compression fractures confirmed by WS-MRI divide in three groups. 82 patients (M/F : 25/57) who had acute fractures only were in group 1, 79 patients who had acute and old fractures were in group 2, and 20 patients who had acute fractures after vertebroplasy were in group 3. To analyze the fracture type and adjacency of accompanied fractures in acute osteoporotic spinal compression fractures which combined chronic fracture or vertebroplasty using the WS-MRI and compared with the control group who had no spinal fractures measured the SVA. In all groups, we measured BMI, and BMD. RESULTS: In WS-MRI, 31 patients in group 1 had L1 which was the most common fracture site. Twenty two patients had chronic fractures and more than 3 remote levels at the acute fracture site in group 2 and especially among there 14 patients have each level in cervicothoracic and lumbar vertebrae. In group 3 had old fracture and adjacent fracture was 14 and 11 patients. Compared with the control group, all groups had increased SVA, especially in group 2 which has acute and chronic compression fractures. They have no significantly difference of BMI in each group, but group 2 and 3 had a significant lower BMD than group 1. CONCLUSION: Fourteen patients of coexisting fractures in acute osteoporotic spinal compression fractures with WS-MRI which could be missed in the conventional MRI. Additionally this study suggests that longer SVA causes sagittal imbalance, and BMD is more relative than BMI in refractures of chronic compression fracture patients.

The Relationship between Sagittal Spinal Alignment and Surgical Results in Degenerative Lumbar Scoliosis with Spinal Stenosis / 대한척추외과학회지

STUDY DESIGN: A retrospective study. OBJECTIVES: To analyze the correlation between clinical results and sagittal vertical axis, clinical results and total lumbar lordosis in degenerative lumbar scoliosis with spinal stenosis. SUMMARY OF LITERATURE REVIEW: There has been no report about the relation between sagittal spinal alignment and surgical outcome of degenerative lumbar scoliosis. MATERIALS AND METHODS: We reviewed 38 surgical cases of degenerative lumbar scoliosis from February 1997 to February 2001 with an average follow-up of 35 months. In whole spine standing AP and lateral radiographs, scoliotic angle(Cobb method), total lumbar lordosis(L1-S1) and the sagittal vertical axis(C7 plumb line) were measured. In lumbar flexion-extension and standing side bending views, the lateral translation was measured and instability was determined. Clinical results were evaluated based on the Kirkaldy-Willis criteria. RESULTS: The scoliotic angles at preoperative, postoperative and follow-up were 15.0+/-4.9, 5.3+/-3.1 and 7.1+/-3.7 degrees retro-spectively. Total lumbar lordosis were 28.7+/-6.1, 40.6+/-7.3 and 35.1+/-10.2 degrees retrospectively. Sagittal vertical axis at preoperative and the last follow-up were 3.3+/-3.2 and 0.1 +/-3.3 cm retrospectively. According to Kirkaldy-Willis criteria, 6 cases were excellent, 24 cases good, 7 cases fair and 1 case poor. There was no statistical correlation between total lumbar lordosis and the clinical results (r=-0.061, p=0.717). Sagittal vertical axis was significantly correlated with the clinical results (r=0.519, p=0.001). CONCLUSIONS: For improvement of surgical outcome of degenerative lumbar scoliosis, the sagittal vertical axis should be used as a parameter of sagittal alignment rather than the total lumbar lordosis.