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Background: Sagittal and coronal standing radiographs have been the standard imaging for assessing spinal alignment. However, their disadvantages include distortion at the image edges and low interobserver reliability in some parameters. EOS® is a low-dose biplanar digital radiographic imaging system that can avoid distortion by obtaining high-definition images., Methods: This study aimed to evaluate spinopelvic parameters in conventional lateral C1S1 upright radiographs and EOS® images and compare them. Patients with non-deformity changes were subjected to routine clinical examinations. Plain AP and lateral X-ray radiographs were obtained along the entire spine length. Patients were also referred for full-length EOS® of the spine. Thoracic Kyphosis (TK), Lumbar Lordosis (LL), Pelvic Tilt (PT), Sacral Slope (SS), Pelvic Incidence (PI), and Sagittal Vertical Axis (SVA) were measured in the two studies by an orthopedic surgeon and a radiologist using PACS software. Also, the orthopedic surgeon evaluated the studies again after two weeks. Intra- and inter-observer reliability was then assessed using the interclass correlation coefficient (ICC). Also, the coefficient of variation was used to assess intra- and inter-observer reliability. Bland-Altman plots were drawn for each parameter., Results: The mean age was 48.2 ± 6.6 years. Among the 50 patients, 30 (60%) were female. The mean ICC for TK, LL, PT, SS, PI, and SVA in EOS® images are 0.95, 0.95, 0.92, 0.90, 0.94, and 0.98, respectively, and in C1S1 radiography images, it was 0.92, 0.87, 0.94, 0.88, 0.93, and 0.98, respectively which shows good to excellent results. The coefficient of variation for intraobserver reliability was relatively low (< 18.6%), while it showed higher percentages in evaluating interobserver reliability (< 54.5%). Also, the Bland-Altman plot showed good agreement for each parameter., Conclusion: Spinopelvic parameters, e.g., TK, LL, SS, PI, and SS, in EOS® are reliable and comparable to those in conventional lateral upright C1S1 radiographs., (© 2024. The Author(s).)

Purpose: Three-column osteotomies (TCOs) and minimally invasive techniques such as anterior column realignment (ACR) are powerful tools used to restore lumbar lordosis and sagittal alignment. We aimed to appraise the differences in construct and global spinal stability between TCOs and ACRs in long constructs., Methods: We identified consecutive patients who underwent a long construct lumbar or thoracolumbar fusion between January 2016 and November 2021. "Long construct" was any construct where the uppermost instrumented vertebra (UIV) was L2 or higher and the lowermost instrumented vertebra (LIV) was in the sacrum or ileum., Results: We identified 69 patients; 14 (20.3%) developed PJK throughout follow-up (mean 838 days). Female patients were less likely to suffer PJK (p = 0.009). TCO was more associated with open (versus minimally invasive) screw/rod placement, greater number of levels, higher UIV, greater rate of instrumentation to the ilium, and posterior (versus anterior) L5-S1 interbody placement versus the ACR cohort (p < 0.001, p < 0.001, p < 0.001, p < 0.001, p = 0.005, respectively). Patients who developed PJK were more likely to have undergone ACR (12 (32.4%) versus 2 (6.3%, p = 0.007)). The TCO cohort had better improvement of lumbar lordosis despite similar preoperative measurements (ACR: 16.8 ± 3.78°, TCO: 23.0 ± 5.02°, p = 0.046). Pelvic incidence-lumbar lordosis mismatch had greater improvement after TCO (ACR: 14.8 ± 4.02°, TCO: 21.5 ± 5.10°, p = 0.042). By multivariate analysis, ACR increased odds of PJK by 6.1-times (95% confidence interval: 1.20-31.2, p = 0.29)., Conclusion: In patients with long constructs who undergo ACR or TCO, we experienced a 20% rate of PJK. TCO decreased PJK 6.1-times compared to ACR. TCO demonstrated greater improvement of some spinopelvic parameters., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To identify variables that may contribute to the development of proximal junctional failure (PJF) in patients with long lumbo-sacral and thoraco-lumbo-pelvic constructs undergoing anterior column realignment (ACR) with anterior longitudinal ligament release (ALLR)., Methods: Data of patients with adult spinal deformity who underwent ACR with ALLR at L3-4 were collected retrospectively from medical records and a prospectively maintained spine research database between 2016 and 2022., Results: Eleven (41%) developed PJF at a mean of 24 ± 21 months from the index surgery. The cohort was then divided into 2 groups for analysis, 13 subjects in the high pelvic incidence (PI) group (defined as PI ≥ 55°) and 14 subjects in the low PI group (defined as PI < 55°). Visual Analog Scale for back pain and Oswestry Disability Index decreased from 9.5 to 2.1 and 61 to 10 in the high PI group, and from 8.9 to 2.4 and 60.9 to 10.3 in the low PI group, respectively. PI (P = 0.004), sacral slope (P = 0.005), and postoperative PI-lumbar lordosis mismatch (P = 0.02) were found to be significant predictors of PJF. The receiver operator curve revealed a cutoff PI value ≤ 53° (95% confidence interval: 52°-64°), below which the risk of PJF becomes significantly higher in patients undergoing ACR with ALLR at L3-4., Conclusions: PI may be a predictor of PJF and highly correlates with ACR-ALLR levels. In patients undergoing L3-4 ACR-ALLR, a PI value of ≤53° is associated with a significantly elevated risk of PJF. Preoperative planning of ACR-ALLR level based on normal sagittal alignment in otherwise healthy individuals may mitigate the risk of PJF development in patients with adult spinal deformity treated with ACR-ALLR., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Few studies describe thoracolumbar disc herniation (TLDH) as an isolated category, it is frequently classified as the lower thoracic spine or upper lumbar spine. Thus, less is known about the morphology and aetiology of TLDH compared to lumbar disc herniation (LDH). The aim of study is to investigate sagittal alignment in TLDH and analyze sagittal profile with radiographic parameters., Methods: Data from 70 patients diagnosed with TLDH were retrospectively reviewed. The thoracic-lumbar alignment was depicted by description of curvatures (the apex of lumbar curvature, the apex of thoracic curvature, and inflexion point of the two curvatures) and radiographic parameters from complete standing long-cassette spine radiographs. The rank sum test was utilised to compare radiographic parameter values in each subtype., Results: We found two subtypes differentiated by the apex of thoracic kyphotic curves. The sagittal profile was similar to that of the normal population in type I, presenting the apex of the thoracic kyphotic curve located in the middle thoracic spine. The well aligned thoracic-lumbar curve was disrupted in type II, presenting the apex of the thoracic kyphotic curve located in the thoracolumbar region in type II patients. Thirty-six patients were classified as type I, and 34 patients were classified as type II. The mean sagittal vertical axis, T1 pelvic angle and L1 pelvic angle were 27.9 ± 24.8°, 8.2 ± 7.3° and 6.2 ± 4.9°, respectively. There was significant difference (p < 0.001) of thoracolumbar angle between type I (14.9 ± 7.9°) and type II patients (29.1 ± 13.7°)., Conclusions: We presented two distinctive sagittal profiles in TLDH patients, and a regional kyphotic deformity with a balanced spine was validated in both subtypes. In type I patients, disc degeneration was accelerated by regional kyphosis in the thoracolumbar junction and eventually caused disc herniation. In type II patients, excessive mechanical stress was directly loaded at the top of the curve (thoracolumbar apex region) rather than being diverted by an arc as in a normal population or type I patients. Mismatch between shape and sacral slope value was observed, and better agreement was found in Type II patients.

Purpose: To analyze how pedicle subtraction osteotomy (PSO) treatment of severe Scheuermann thoracolumbar kyphosis (STLK) using pedicle screw instrumentation affects sagittal spinopelvic parameters., Background: The medical literature on the post-surgical effects of treatments such as Ponte osteotomy is limited, but suggests few effects on spinopelvic profiles. Currently, there is no research regarding changes in sagittal spinopelvic alignment upon PSO treatment in STLK patients., Methods: We performed a retrospective study on 11 patients with severe STLK. These patients underwent posterior-only correction surgeries with PSO and pedicle screw instrumentation between 2012 to 2017 in a single institute. Patients were measured for the following spinopelvic parameters: global kyphosis (GK), thoracic kyphosis (TK), thoracolumbar kyphosis (TL), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tile (PT), sacral slope (SS), and administered a Scoliosis Research Society-22 questionnaire (SRS-22) pre-operation, post-operation and at final follow-up., Results: GK improved from a median of 74.1° to 40.0° after surgery, achieving a correction rate of 48.8% with a median correction loss of 0.8°. TK, TL and LL all showed significant difference (P < 0.05) and SVA improved 22.7 (11.6, 30.9) mm post operation. No significant difference was found in pelvic parameters (PI, PT, SS, all P < 0.05). The absolute value of LL- PI significantly improved from a median of 26.5° pre-operation to 6.1° at the final follow-up. 72.7% in this series showed an evident trend of thoracic and lumbar apices migrating closer to ideal physiological segments after surgery. Self-reported scores of pain, self-image, and mental health from SRS-22 revealed significant improvement at final follow-up (all P < 0.05)., Conclusions: PSO treatment of severe STLK with pedicle screw instrumentation can improve spine alignment and help obtain a proper alignment of the spine and the pelvis.

Objective: To investigate the influence of posterior osteotomy on spinopelvic parameters in lumbar degenerative kyphosis (LDK) patients., Methods: The clinical data of 21 patients with lumbar degenerative kyphosis who underwent osteotomy from January 2012 to December 2015 were retrospectively analyzed. There were 5 males and 16 females, aged from 55 to 76 years with an average of (66.24±5.13) years. All patients had taken preoperative and postoperative full length spinal X-ray, analyzing the spinopelvic parameters as thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS)., Results: All operations were successful, the average operative time was 190 min (160 to 220 min) and intraoperative blood loss was 1 000 ml (800 to 1900 ml). Parameters of the patients between preoperative and period 1-year follow-up were as follows : preoperative TK increased from (31.67±21.13) ° to (34.67±11.60) °, LL corrected from (4.76±3.17) ° to (37.41±6.28) °, PT reduced from (33.94±5.01) ° to (20.12±5.36) °, and SS improved from (18.47±2.60) ° to (31.71±4.30) °, SVA restored from (13.24±3.60) cm to (2.82±1.33) cm. There were significant differences of spinopelvic parameters between preoperation and postoperation ( P <0.05)., Conclusion: Posterior osteotomy can effectively reconstruct the sagittal balance of spinopelvis in patients with lumbar degenerative kyphosis. The recovery of lumbar lordosis and sacral slope is closely related to the reconstruction of sagittal balance.

Purpose: To clarify the relationship between sarcopenia and spinopelvic parameters., Methods: Among outpatients of spine surgery department, 126 patients (mean age 77.2 years. M/F = 71/55) were included. We diagnosed patients with sarcopenia using the diagnostic algorithm of the Asian Working Group for Sarcopenia. Spinopelvic parameters and the prevalence of spinopelvic mismatch (pelvic incidence minus lumbar lordosis ≥ 10°) were investigated and compared between patients with and without sarcopenia. Furthermore, we compared the spinopelvic parameters between the Sarcopenia and No Sarcopenia groups under each condition of spinopelvic match and mismatch., Results: The prevalence of sarcopenia in this study was 21.4%. Overall, the spinopelvic parameters except thoracic kyphosis (TK) (Sarcopenia: 34.7°, No Sarcopenia: 24.3°, p < 0.01) were not significantly different between the Sarcopenia and No Sarcopenia groups. Prevalence of patients with spinopelvic mismatch was also not significantly different between the Sarcopenia and No Sarcopenia groups (37.0% vs. 42.4%, p = 0.66). Among patients without spinopelvic mismatch, there was no spinopelvic parameter with a significant difference between the 2 groups. However, among patients with spinopelvic mismatch, sagittal vertebral axis (SVA) (115.7 mm vs. 58.7 mm, p < 0.01) and TK (36.6° vs. 21.3°, p < 0.01) of the Sarcopenia group were significantly larger than those of the No Sarcopenia group. Moreover, sarcopenia was independently related to a significant increase in SVA (β = 50.7, p < 0.01) and TK (β = 14.0, p < 0.01) in patients with spinopelvic mismatch, after adjustment for age., Conclusions: Sarcopenia is related to spinal sagittal imbalance because of insufficient compensation by flattening thoracic kyphosis in patients with spinopelvic mismatch. These slides can be retrieved under Electronic Supplementary Material.

Purpose: To investigate the relationship between preoperative and postoperative spinopelvic alignment and occurrence of DJK/DJF., Study Design/setting: This was a retrospective observational cohort study., Patient Sample: The sample included 40 patients who underwent posterior correction of SK from January 2006 to December 2014., Outcome Measures: Correlation analysis between the preoperative and postoperative spinopelvic alignment parameters and development of DJK over the course of the study period were studied., Methods: Whole spine X-rays obtained before surgery, 3 months after surgery and at the latest follow-up were analyzed. The following parameters were measured: maximum of thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lower instrumented vertebra (LIV) and LIV plumb line. Development of DJK was considered as the primary end point of the study. The patient population was split into a control and DJK group, with 34 patients and 6 patients, respectively. Statistic analysis was performed using unpaired t test for normal contribution and Mann-Whitney test for skew distributed values. The significance level was set to 0.05., Results: DJK occurred in 15% (n = 6) over the study period. There was a significantly lower postoperative TK for the group with DJK (42.4 ± 5.3 vs 49.8 ± 6.7, p = 0.015). LIV plumb line showed higher negative values in the DJK group (-43.6 ± 25.1 vs -2.2 ± 17.8, p = 0.0435). Furthermore, postoperative LL changes were lower for the DJK group (33.84 ± 13.86% vs 31.77 ± 14.05, p < 0.0001.) The age of the patients who developed DJK was also significantly lower than that of the control group (16.8 ± 1.7 vs 19.6 ± 4.9, p = 0.0024.) CONCLUSIONS: SK patients who developed DJK appeared to have a significantly higher degree of TK correction and more negative LIV plumb line. In addition, there may be a higher risk for DJK in patients undergoing corrective surgery at a younger age.

Background: Recently, a grayscale inversion view was reported to improve intra- and inter-observer reliabilities in measuring coronal curvature with Cobb and pedicle methods in scoliosis patients. However, the grayscale transformation has never been applied to the measurements of spinopelvic parameters. The purpose of this study was to compare the measurement reliabilities of the spinoplevic sagittal parameters between the 'Standard View' and the 'Grayscale Inversion View' in normal adult populations., Methods: A total of 30 asymptomatic subjects aged between 30 and 40 years were included in this study. Whole-spine posteroanterior radiographs were used to measure the spinoplevic sagittal parameters including thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), sacral slope (SS) and pelvic tilt (PT) in both standard view and grayscale inversion view. Two independent observers measured the parameters twice at a 2-week interval. Intra- and inter-observer reliabilities were compared between the two radiographic views. The absolute differences between the two sets of measurements on each view were calculated and compared., Results: The intra-class correlation coefficients (ICCs) of PI, PT and SVA were greater in the grayscale inversion view than in the standard view (0.972 vs 0.817, 0.937 vs 0.833 and 0.964 vs 0.901 for observer 1, respectively; 0.990 vs 0.826, 0.995 vs 0.842 and 0.969 vs 0.919 for observer 2, respectively). Overall, the improvement of ICC was greater in parameters of sagittal pelvic alignment than in those of sagittal spinal alignment. As for the mean absolute differences between two measurements, significant differences existed between the two views in terms of PI, PT and SVA (p = 0.014, 0.016 and 0.011 for observer 1, respectively; p = 0.014, 0.025 and 0.046 for observer 2, respectively)., Conclusions: A grayscale inversion view provided improved intra- and inter-observer reliabilities in measuring spinoplevic alignment when compared with a standard view. This view was more useful in subjects whose pelvic anatomical structures can't be identified clearly on the standard X-ray view.

Background Context: Surgical correction of Scheuermann kyphosis (SK) is challenging and plagued by relatively high rates of proximal junctional kyphosis and failure (PJK and PJF). Normal sagittal alignment of the spine is determined by pelvic geometric parameters. How these parameters correlate with the risk of developing PJK in SK is not known., Purpose: The study aimed to investigate the relationship between preoperative and postoperative spinopelvic alignment and occurrence of PJK and PJF., Study Design/setting: This is a retrospective observational cohort study., Patient Sample: The sample included 37 patients who underwent posterior correction of SK from January 2006 to December 2012., Outcome Measures: The outcome measure was correlation analysis between preoperative and postoperative spinopelvic alignment parameters and the development of PJK over the course of the study period., Methods: Whole spine x-rays obtained before surgery, 3 months after surgery, and at the latest follow-up were analyzed. The following parameters were measured: thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). The development of PJK was considered the primary end point of the study. Patient population was split into a control and a PJK group; repeated-measures analysis of variance was used to assess group and time differences., Results: Seven patients developed PJK over the study period. Although the severity of the preoperative deformity (TK) did not differ significantly between the two groups, preoperative PI was significantly higher in the PJK group (51.9°C±8.6°C vs. 42.7°C±8.8°C, p=.018). Postoperative correction of TK was similar between the two groups (39.3% and 41.2%, p=.678) and final LL did not differ as well (53.6°C±9.2°C vs. 51.3°C±11.5°C). However, because PJK patients had larger preoperative PI values, a significant deficit of LL was observed at final follow-up in this group compared with the control group (ΔLL -10.5°C±9.8°C vs. 0.6°C±10.5°C, p=.013)., Conclusions: Scheuermann kyphosis patients who developed PJK appeared to have a significant postoperative deficit of LL (lumbopelvic mismatch). Lumbar lordosis decreases after surgery following correction of TK; therefore, TK correction should be planned according to preoperative PI values to avoid excessive reduction of LL in patients with higher PI values., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background Context: Knowledge of sagittal spinopelvic parameters is important for the treatment of cerebral palsy (CP) because they differ in the normal population and can induce symptoms., Purpose: To analyze the sagittal spinal alignment and the pelvic orientation in CP., Study Design: Radiological analysis of patients with CP., Methods: The study and control groups comprised 57 CP patients and 24 healthy volunteers, respectively. All the patients underwent lateral radiography of the whole spine including hip joints. The radiographic parameters examined were sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), S1 overhang (OH), thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), lumbar lordosis (LL1 and 2), and sagittal balance (SB). Statistical analysis was performed to identify the significant differences between the two study groups. In addition, correlations were sought between the parameters and symptoms., Results: The PT and OH were significantly smaller in the CP patients, whereas SS, TLK, LL1, LL2, and SB were significantly greater (p<.05). Correlation analysis revealed significant relationships between the sagittal parameters. Specifically, PI was found to be associated with SS, PT, and OH, whereas the spinal parameters LL1 and LL2 were found to be related to TK and SB. Between spine and pelvic parameters, LL1 and LL2 were found to be related to SS, PT, PI, and OH and in addition, SB was found to be related to TLK, LL1, and LL2. An analysis of relations between the symptoms and parameters revealed a positive correlation between the severities of symptoms and PT, OH, and TLK (r=0.300, p=.023; r=0.306, p=.020; r=0.289, p=.029, respectively)., Conclusions: A significant difference was observed in the sagittal spinopelvic parameters in the CP and normal control groups and was possibly related to the symptoms. The study shows that the evaluations of sagittal spinopelvic parameters could be useful during the treatment of disorders associated with CP., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Aim: In order for a person to stand in a balanced way, the pelvis and spine must be in harmony. The aim of this study was to determine the normal ranges of spinopelvic parameters in children and adolescents in Türkiye. Material and Method: In our study, computed tomography images of 1018 healthy 7-17 year olds were examined. As a result of this examination, sacrum pubic incidence, lumbar lordosis, sacral slope, sacral kyphosis, pelvic tilt and pelvic incidence were measured. Results: The sacrum pubic incidence was 58.71±6.17°, sacral slope 37.26±5.77, lumbar lordosis 42.98±8.06°, sacral kyphosis 21.27±9.96°, pelvic incidence 46.77±6.38, and pelvic tilt 9.51±5.06°. The calculations revealed that, with age, all parameters except pelvic tilt increased significantly. A statistically significant difference was found between the age groups. Conclusion: The results of this study will contribute to the existing literature and may give clinicians insight into sagittal corrections in spine and pelvic surgery. [ABSTRACT FROM AUTHOR]

Study Design: A retrospective cross-sectional study.Objective: To assess the association between spinal muscle morphology and spinopelvic parameters in lumbar fusion patients, with a special emphasis on lumbar lordosis (LL).Summary Of Background Data: Maintenance of sagittal alignment relies on muscle forces, but the basic association between spinal muscles and spinopelvic parameters is poorly understood.Materials and Methods: Patients operated between 2014 and 2017 who had both lumbar magnetic resonance imaging scan and standing whole-spine radiographs within six months before surgery were included. Muscle measurements were conducted on axial T2-weighted magnetic resonance images at the superior endplate L3-L5 for the psoas and L3-S1 for combined multifidus and erector spinae (paraspinal) muscles. A pixel intensity threshold method was used to calculate the total cross-sectional area (TCSA) and the functional cross-sectional area (FCSA). Spinopelvic parameters were measured on lateral standing whole-spine radiographs and included LL, pelvic incidence (PI), PI-LL mismatch, pelvic tilt, sacral slope, thoracic kyphosis, and sagittal vertical axis. Analyses were stratified by biological sex. Multivariable linear regression analyses with adjustments for age and body mass index (BMI) were performed.Results: A total of 104 patients (62.5% female) were included in the analysis. The patient population was 90.4% White with a median age at surgery of 69 years and a median BMI of 27.8 kg/m 2 . All muscle measurements were significantly smaller in women. PI, pelvic tilt, and thoracic kyphosis were significantly greater in women. PI-LL mismatch was 6.1° (10.6°) in men and 10.2° (13.5°) in women ( P =0.106), and sagittal vertical axis was 45.3 (40.8) mm in men and 35.7 (40.8) mm in women ( P =0.251). After adjusting for age and BMI, paraspinal TCSA at L3-L5, and paraspinal FCSA at L4 showed significant positive associations with LL in women. In men, psoas TCSA at L5 and psoas FCSA at L5 showed significant negative associations with LL, but none of the paraspinal muscle measurements.Conclusion: Our findings indicate that psoas and lumbar spine extensor muscles interact differently on LL among men and women, creating a unique mechanical environment.Level Of Evidence: Level 4. [ABSTRACT FROM AUTHOR]

Study Design: Cross-sectional study. Purpose: To evaluate sagittal balance, pulmonary function, and spinopelvic parameters in patients with healed spinal tuberculosis with severe thoracic kyphosis. Overview of Literature: Deterioration of neurological function is an absolute indication of surgical intervention in severe posttubercular kyphosis, but the relationship of compromise in lung function and spinal alignment with severity of kyphosis is still unclear. Methods: Twenty patients (age, 14-60 years) with healed spinal tuberculosis with thoracic kyphosis >50° were included. Lateralview radiography of the whole spine, including both hips, was performed for assessment of kyphotic angle (K angle), sagittal balance, lumbar lordosis, and spinopelvic parameters. Pulmonary function was assessed by measuring the forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and their ratio (FEV1/FVC) by spirometry. Results: A positive correlation between severity of kyphosis and sagittal imbalance was noted, with compensatory mechanisms maintaining the sagittal balance in only up to 80° of dorsal kyphosis. In >80° of kyphosis, FVC was found to be markedly decreased (mean FVC=50.6%). The mean K angle was lower in subjects with lower thoracic kyphosis. In lower thoracic kyphosis, due to short lordotic and long kyphotic curves, both lumbar lordosis and pelvic retroversion worked at compensation, whereas, in middle thoracic kyphosis, due to long lordotic curve, only lumbar lordosis was required. Normal pulmonary function (mean FVC, 83.0%) and lesser kyphotic deformity (mean K angle in adolescents, 69.8°; in adults, 94.4°) were found in adolescents. Conclusions: In >80° of thoracic kyphosis, there is sagittal imbalance and a markedly affected pulmonary function. Such patients should be offered corrective surgery if they are symptomatic and medically fit to undergo the procedure. However, whether the surgical procedure would result in improved pulmonary function and sagittal balance needs to be evaluated by a follow-up study. [ABSTRACT FROM AUTHOR]

To determine whether the L3–L4 disc angle may be a surrogate marker for global lumbar alignment in thoracolumbar fusion surgery and to explore the relationship between radiographic and patient-reported outcomes after thoracolumbar fusion surgery. Retrospective chart review was conducted on patients who had undergone a lumbar fusion involving levels from T9 to pelvis. EuroQol-Five Dimension (EQ-5D-3L) scores and adverse events including adjacent-segment disease and degeneration, pseudoarthrosis, proximal junctional kyphosis, stenosis, and reoperation were collected. Pre- and postoperative spinopelvic parameters were measured on weight-bearing radiographs, with the L3–L4 disc angle of novel interest. Univariate logistic and linear regression were performed to assess the associations of radiographic parameters with adverse event incidence and improvement in EQ-5D-3L, respectively. In total, 182 patients met inclusion criteria. Univariable analysis revealed that increased magnitude of L3–L4 disc angle, anterior pelvic tilt, and pelvic incidence measures are associated with increased likelihood of developing postoperative adverse events. Conversely, increased lumbar lordosis demonstrated a decreased incidence of developing a postoperative adverse event. Linear regression showed that radiographic parameters did not significantly correlate with postoperative EQ-5D-3L scores, although scores were significantly improved postfusion in all dimensions except Self-Care (P = 0.51). L3–L4 disc angle magnitude may serve as a surrogate marker of global lumbar alignment. The degree of spinopelvic alignment did not correlate to improvement in EQ-5D-3L score in the present study, suggesting that quality of life metric change may not be a sensitive or specific marker of postfusion alignment. [ABSTRACT FROM AUTHOR]

Study Design: Systematic review and meta-analysis.Objective: The purpose of the study was to compare the outcomes and after spinal fusion with or without iliac screw (IS) insertion for patients with adult spinal deformity (ASD).Summary Of Background Data: The number of patients undergoing multilevel spinal stabilization for the treatment of ASD is growing. However, the selection of spinopelvic fixation for ASD patients with long fusion is controversial.Methods: A comprehensive literature search was performed without time restriction according to the guidelines from the Cochrane Collaboration in May 2020 using PubMed, EMBASE, and the Cochrane Library. The comparison of the two types of fixation was evaluated by spinopelvic parameters, incidence rate of complications, rate of revision, and clinical outcomes at the last follow-up.Results: The literature search identified 422 records, of which eight studies were included for meta-analysis with a total of 439 patients. All the included studies provided level III evidence. There was no significant difference in the sagittal vertical axis, pelvic incidence, the proximal junctional kyphosis rates, the pseudarthrosis rates, the revision rates, and the clinical outcomes at the last follow-up between those who receive sacrum fixation and sacropelvic fixation. Nevertheless, greater lumbar lordosis (LL) (weighted mean difference [WMD], 4.15; 95% confidence interval [CI] 2.46-5.84, P < 0.01), greater sacral slope (SS) (WMD, 2.32; 95% CI 1.21-3.43, P < 0.01), and lower rate of the distal instrumentation instability (odds ratio, 0.25; 95% CI 0.10-0.61, P = 0.002) were observed in IS group between the comparison.Conclusion: The clinical outcomes in the IS group were similar to those in the non-IS group, but the application of the IS significantly restored LL, prevented decompensation, and reduced the occurrence of the distal instrumentation instability. Therefore, the IS may be a good choice for the operative treatment of ASD patients with sagittal malalignment and other risks of lumbosacral fracture, metal breakage, and screw pullout.Level of Evidence: 3. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective case series.Objective: The present study aimed to determine the characteristics of patients with adult spinal deformity (ASD) with a discrepancy between standing and walking postures.Summary Of Background Data: Standing radiographic parameters are typically used to evaluate patients with ASD. Patients with ASD with relatively good sagittal alignment on standing radiography have, however, been reported to walk with a forward trunk tilt.Methods: Patients with ASD (n = 93; 13 men, 80 women; mean age, 65.0 yr) who underwent corrective surgery and preoperative gait analysis at our hospital between 2011 and 2013 were included. Spine radiographs and gait analysis data were acquired preoperatively. Standing-trunk tilt angle (STA) on lateral standing x-ray, gait-trunk tilt angle (GTA) from lateral gait images, and radiographic parameters of the spine and pelvis (lumbar lordosis [LL], pelvic tilt, and sagittal vertical axis) were measured. We calculated the increasing trunk tilt angle (ITA), by subtracting the STA from the GTA, for use as an index of discrepancy between standing posture and sagittal balance during walking. We examined the relation between radiographic parameters and ITA.Results: The mean preoperative STA and GTA were 3.5° and 11.1°, respectively. The mean preoperative ITA, which represents the degree of discrepancy between standing posture and sagittal balance during walking, was 7.6°. The mean preoperative sagittal vertical axis, LL, pelvic incidence (PI), pelvic tilt, and PI minus LL were 102.6 mm, 20.3°, 52.9°, 32.1°, and 32.6°, respectively. The PI minus LL mismatch was positively correlated with the ITA (R = 0.237, P = 0.023). In particular, patients with ASD with a PI minus LL mismatch of more than 40° had a significantly greater ITA.Conclusion: Gait analysis revealed that a preoperative standing-walking discrepancy is associated with severe PI - LL mismatch.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

Background: Recently, a grayscale inversion view was reported to improve intra- and inter-observer reliabilities in measuring coronal curvature with Cobb and pedicle methods in scoliosis patients. However, the grayscale transformation has never been applied to the measurements of spinopelvic parameters. The purpose of this study was to compare the measurement reliabilities of the spinoplevic sagittal parameters between the 'Standard View' and the 'Grayscale Inversion View' in normal adult populations. Methods: A total of 30 asymptomatic subjects aged between 30 and 40 years were included in this study. Wholespine posteroanterior radiographs were used to measure the spinoplevic sagittal parameters including thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), sacral slope (SS) and pelvic tilt (PT) in both standard view and grayscale inversion view. Two independent observers measured the parameters twice at a 2-week interval. Intra- and inter-observer reliabilities were compared between the two radiographic views. The absolute differences between the two sets of measurements on each view were calculated and compared. Results: The intra-class correlation coefficients (ICCs) of PI, PT and SVA were greater in the grayscale inversion view than in the standard view (0.972 vs 0.817, 0.937 vs 0.833 and 0.964 vs 0.901 for observer 1, respectively; 0.990 vs 0. 826, 0.995 vs 0.842 and 0.969 vs 0.919 for observer 2, respectively). Overall, the improvement of ICC was greater in parameters of sagittal pelvic alignment than in those of sagittal spinal alignment. As for the mean absolute differences between two measurements, significant differences existed between the two views in terms of PI, PT and SVA (p = 0.014, 0.016 and 0.011 for observer 1, respectively; p = 0.014, 0.025 and 0.046 for observer 2, respectively). Conclusions: A grayscale inversion view provided improved intra- and inter-observer reliabilities in measuring spinoplevic alignment when compared with a standard view. This view was more useful in subjects whose pelvic anatomical structures can't be identified clearly on the standard X-ray view. [ABSTRACT FROM AUTHOR]

Purpose: To analyze changes in sagittal spinopelvic parameters (SSPs) after surgical treatment of Scheuermann's Kyphosis (SK).Methods: We analyzed 20 patients affected by SK and subjected to posterior correction of the kyphosis by facetectomy, Ponte osteotomy, fusion and multilevel instrumentation with pedicle screw system. Four spinal and three pelvic parameters were measured: sagittal vertical axis (SVA), thoracic kyphosis (TK), thoracolumbar kyphosis, lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS) and pelvic tilt (PT). Analysis of changes in postprocedural SSPs compared to preoperative values was performed.Results: TK passed from 78.6° preoperatively to 45.8° (p = 0.003). LL passed from 74.5° preoperatively to 53.5° (p = 0.01). No significant changes occurred in SVA, SS, PT and PI compared to preoperative values.Conclusion: We confirm the positive effect of surgery by Ponte osteotomy and posterior spinal fusion on TK and LL in patients with SK. In our experience, pelvic parameters did not change after surgery. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this retrospective clinical study is to evaluate the effect of growing rod lengthening technique on sagittal balance in relationship with the spinopelvic parameters, in early onset scoliosis (EOS). Methods: Twenty-three patients (18 female, 5 male), with a mean age of 8.3 years during the operation (range 3.2-12.2), with EOS due to various etiologies were operated using growing rod (8 single, 15 dual) technique, between the years 2007 and 2011. The patients were operated in two different institutions and were evaluated retrospectively via the parameters on the radiographic charts including the mean curve angle, T1-S1 distance, cervical lordosis, thoracic kyphosis, lumbar lordosis, sagittal and coronal balance, pelvic tilt, sacral slope and pelvic incidence. The parameters were measured in the preoperative and the early postoperative periods and during the last follow-up. The data obtained from the measurements were evaluated statistically. Complications were also noted. Results: The mean follow-up period was 34.2 months (range 24-57.6). The mean thoracic kyphosis angle was 53.6° (range 25°-119°) preoperatively, 39.6° (range 20°-61°) early postoperatively ( p < 0.05) and 39.9° (range 21°-65°) during the last follow-up ( p < 0.05). The mean lumbar lordosis angle was −46.1° (range −67° to −13°) preoperatively, −41° (range −64° to −11°) early postoperatively ( p > 0.05) and −39.7° (range −62° to −16°) during the last follow-up ( p > 0.05). Average sagittal balance was measured as 0.2 cm (range −7 to 24.7 cm) preoperatively, −0.1 cm (range −6.6 to 8.5 cm) initial postoperatively ( p > 0.05) and −0.2 cm (range −7.3 to 13.5 cm) during the last follow-up ( p > 0.05). The average pelvic incidence was found as 46.4° (range 27°-83°) preoperatively, 45.2° (range 28°-78°) ( p > 0.05) early postoperatively and 45.7° (range 28°-82°) during the last follow-up ( p > 0.05). We have encountered complications in 14 patients. These consisted of eight rod fractures, seven screw pull-outs, four hook dislodgements, three proximal junctional kyphosis, two screw nut loosening, one lamina fracture, one skin slough, one superficial wound infection and one deep wound infection. Conclusion: Significant improvement was found in the global thoracic kyphosis angle, by comparing the preoperative, the early postoperative and the last follow-up parameters statistically ( p < 0.05). There was no statistically significant improvement in the spinopelvic parameters ( p > 0.05). We claim that growing rod technique doesn't provide statistically significant improvement, in the sagittal spinal and the spinopelvic parameters, except for the kyphosis, in the treatment of EOS patients. [ABSTRACT FROM AUTHOR]

Purpose: Many degenerative phenomena frequently result into kyphotic lumbar and thoracic deformities or cause their progression combined with deformities on the frontal plane of the spine. In these patients, the progression of the sagittal imbalance may lead to a series of disabling functional and painful consequences. The analysis of the spinopelvic parameters biases the choice of the correction surgical strategy aimed at restoring a good tri-dimensional and sagittal balance of the spine. Materials and methods: Sample included 62 patients treated in our Operation Unit that were enrolled for evaluation; they were affected with prevailing sagittal deformities. Results: Clinical results were evaluated through the administration of SF-36, Oswestry Disability Index (ODI), Roland Morris (RM), and visual analogical scale (VAS). Conclusions: In our experience, patients with sagittal imbalance and short fusion areas show a higher risk of correction loss; the arthrodesis area must include the thoracolumbar junction, and it is often necessary to include the whole thoracic spine in the arthrodesis area. This is to avoid any loss of correction, implants mobilization, and proximal hyperkyphosis. [ABSTRACT FROM AUTHOR]

Background: There were several reports describing the biomechanics and microstructure of multifidus muscles in patients with lumbar disc herniation. However, correlations between lumbar multifidus muscle atrophy (LMA), spinopelvic parameters, and severity of adult degenerative scoliosis (ADS) have not been investigated. The study evaluated the impact of LMA and spinopelvic parameters on the severity of ADS. Methods: One hundred and thirty-two patients with ADS were retrospectively reviewed. Standing whole-spine X-ray was used to evaluate the coronal (coronal Cobb angle, CA; coronal vertical axis, CVA) and sagittal (sagittal vertical axis, SVA; thoracic kyphosis, TK; lumbar lordosis, LL; pelvic incidence, PI; pelvic tilt, PT; sacral slope, SS) parameters. LMA was evaluated on axial T2-weighted magnetic resonance imaging (MRI) at intervertebral levels above and below the vertebra at the apex of the scoliotic curve. Clinical symptoms were evaluated by the Oswestry Disability Index (ODI) and the Japanese Orthopaedic Association (JOA) score. Multiple linear regression was used to assess correlations between LMA, spinopelvic parameters, and severity of scoliosis. Results: LL and PT were negatively correlated with CA (P < 0.001); LL was positively correlated with SVA (P < 0.001). PI was positively correlated with CA (P < 0.001) and CVA (P < 0.001). PT (P < 0.001) and SS (P < 0.001) were negatively correlated with CVA. SS was negatively correlated with SVA (P < 0.001). Concave LMA at the upper or lower intervertebral level of the apical vertebra was positively correlated with CA (P ≤ 0.001); convex LMA at the upper or lower intervertebral level was negatively correlated with CA (P < 0.001). Convex LMA at the upper intervertebral level and concave LMA at the lower intervertebral level of the apical vertebra were negatively correlated with the SVA (P ≤ 0.001). At the upper intervertebral level, LMA on the concave side was positively correlated with CVA (P = 0.028); LMA on the convex side was negatively correlated with CVA (P = 0.012). PI was positively correlated with ODI (P < 0.001); PT (P < 0.001) and SS (P < 0.001) were negatively correlated with ODI. At the lower intervertebral level, LMA on the concave side was positively correlated with ODI (P = 0.038); LMA on the convex side was negatively correlated with ODI (P = 0.011). PI was positively correlated with JOA (P < 0.001); PT (P < 0.001) and SS (P < 0.001) were negatively correlated with JOA. Conclusions: Spinopelvic parameters are correlated with the severity of ADS. Asymmetric LMA at both upper and lower intervertebral levels of the apical vertebra is positively correlated with CA. LMA on the diagonal through the apical vertebra is very important to maintain sagittal imbalance via parallelogram effect. LMA at lower intervertebral levels of the apical vertebra may have a predictive effect on ODI. JOA score seems to be more correlated with spinopelvic parameters than LMA. [ABSTRACT FROM AUTHOR]