The lumbar lordosis index: a new ratio to detect spinal malalignment with a therapeutic impact for sagittal balance correction decisions in adult scoliosis surgery

Abstract Restoration of spinal alignment and balance is a major goal of adult scoliosis surgery. In the past, sagittal alignment has been emphasized and was shown to have the greatest impact on functional outcomes. However, recent evidence suggests the impact of coronal imbalance on pain and functional outcomes has likely been underestimated.1,2 In addition, iatrogenic coronal imbalance may be common and frequently results from inadequate correction of the lumbosacral fractional curve.2,3 The “kickstand rod” is a recently described technique to achieve and maintain significant coronal-plane correction.4 Also, of secondary benefit, the kickstand rod may function as an accessory supplemental rod to offload stress and bolster primary instrumentation. This may reduce occurrence of rod fracture (RF) or pseudarthrosis (PA).5 Briefly, this technique involves positioning the kickstand rod on the side of coronal imbalance (along the major curve concavity or fractional curve convexity in our video demonstration). The kickstand rod spans the thoracolumbar junction proximally to the pelvis distally and is secured with an additional iliac screw placed just superior to the primary iliac screw. By using the iliac wing as a base, powerful distraction forces can reduce the major curve to achieve more normal coronal balance. This operative video illustrates the technical nuances of utilizing the kickstand rod technique for correction of severe lumbar scoliosis and coronal malalignment in a 60-yr-old male patient. Alignment correction was achieved and maintained without evidence of RF/PA after nearly 6 mo postoperatively. The patient gave informed consent for surgery and to use imaging for medical publication.

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Sagittal balance correction of idiopathic scoliosis using the in situ contouring technique

European Spine Journal ◽

10.1007/s00586-012-2356-2 ◽

2012 ◽

Vol 21 (10) ◽

pp. 1950-1956 ◽

Cited By ~ 10

Author(s):

Yann Philippe Charles ◽

Julia Bouchaïb ◽

Axel Walter ◽

Sébastien Schuller ◽

Erik André Sauleau ◽

...

Keyword(s):

Idiopathic Scoliosis ◽

Sagittal Balance ◽

Balance Correction

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The Efficacy and Accuracy of Cone Beam CT (O-Arm) Navigation (StealthStation) on Screw Position in Adult Scoliosis Surgery

Global Spine Journal ◽

10.1055/s-0035-1554339 ◽

2015 ◽

Vol 5 (1_suppl) ◽

pp. s-0035-1554339-s-0035-1554339

Author(s):

Jason Strelzow ◽

Danny Mendelsohn ◽

Nicolas Dea ◽

Charles Fisher ◽

Marcel Dvorak ◽

...

Keyword(s):

Cone Beam Ct ◽

Adult Scoliosis ◽

Cone Beam ◽

Scoliosis Surgery ◽

Screw Position

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Limitations and ceiling effects with circumferential minimally invasive correction techniques for adult scoliosis: analysis of radiological outcomes over a 7-year experience

Neurosurgical FOCUS ◽

10.3171/2014.3.focus13585 ◽

2014 ◽

Vol 36 (5) ◽

pp. E14 ◽

Cited By ~ 20

Author(s):

Neel Anand ◽

Eli M. Baron ◽

Babak Khandehroo

Keyword(s):

Minimally Invasive ◽

Cobb Angle ◽

Lumbar Lordosis ◽

Sagittal Plane ◽

Adult Scoliosis ◽

Angle Correction ◽

Scoliosis Correction ◽

Spinopelvic Parameter ◽

Ceiling Effects ◽

The Mean

Object Minimally invasive correction of adult scoliosis is a surgical method increasing in popularity. Limited data exist, however, as to how effective these methodologies are in achieving coronal plane and sagittal plane correction in addition to improving spinopelvic parameters. This study serves to quantify how much correction is possible with present circumferential minimally invasive surgical (cMIS) methods. Methods Ninety patients were selected from a database of 187 patients who underwent cMIS scoliosis correction. All patients had a Cobb angle greater than 15°, 3 or more levels fused, and availability of preoperative and postoperative 36-inch standing radiographs. The mean duration of follow-up was 37 months. Preoperative and postoperative Cobb angle, sagittal vertical axis (SVA), coronal balance, lumbar lordosis (LL), and pelvic incidence (PI) were measured. Scatter plots were performed comparing the pre- and postoperative radiological parameters to calculate ceiling effects for SVA correction, Cobb angle correction, and PI-LL mismatch correction. Results The mean preoperative SVA value was 60 mm (range 11.5–151 mm); the mean postoperative value was 31 mm (range 0–84 mm). The maximum SVA correction achieved with cMIS techniques in any of the cases was 89 mm. In terms of coronal Cobb angle, a mean correction of 61% was noted, with a mean preoperative value of 35.8° (range 15°–74.7°) and a mean postoperative value of 13.9° (range 0°–32.5°). A ceiling effect for Cobb angle correction was noted at 42°. The ability to correct the PI-LL mismatch to 10° was limited to cases in which the preoperative PI-LL mismatch was 38° or less. Conclusions Circumferential MIS techniques as currently used for the treatment of adult scoliosis have limitations in terms of their ability to achieve SVA correction and lumbar lordosis. When the preoperative SVA is greater than 100 mm and a substantial amount of lumbar lordosis is needed, as determined by spinopelvic parameter calculations, surgeons should consider osteotomies or other techniques that may achieve more lordosis.

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Implications of Spinopelvic Alignment for the Spine Surgeon

Neurosurgery ◽

10.1227/neu.0b013e31823262ea ◽

2011 ◽

Vol 70 (3) ◽

pp. 707-721 ◽

Cited By ~ 55

Author(s):

Vivek A. Mehta ◽

Anubhav Amin ◽

Ibrahim Omeis ◽

Ziya L. Gokaslan ◽

Oren N. Gottfried

Keyword(s):

Sagittal Balance ◽

Lumbar Lordosis ◽

Pelvic Incidence ◽

Degenerative Spondylolisthesis ◽

Disease Process ◽

Sacral Slope ◽

Sagittal Imbalance ◽

Spinopelvic Parameters ◽

Spinopelvic Alignment ◽

Spinopelvic Balance

Abstract The relation of the pelvis to the spine has previously been overlooked as a contributor to sagittal balance. However, it is now recognized that spinopelvic alignment is important to maintain an energy-efficient posture in normal and disease states. The pelvis is characterized by an important anatomic landmark, the pelvic incidence (PI). The PI does not change after adolescence, and it directly influences pelvic alignment, including the parameters of pelvic tilt (PT) and sacral slope (SS) (PI = PT 1 SS), overall sagittal spinal balance, and lumbar lordosis. In the setting of an elevated PI, the spineadapts with increased lumbar lordosis. To prevent or limit sagittal imbalance, the spine may also compensate with increased PT or pelvic retroversion to attempt to maintain anupright posture. Abnormal spinopelvic parameters contribute to multiple spinal conditions including isthmic spondylolysis, degenerative spondylolisthesis, deformity, and impact outcome after spinal fusion. Sagittal balance, pelvic incidence, and all spinopelvic parameters are easily and reliably measured on standing, full-spine (lateral) radiographs, and it is essential to accurately assess and measure these sagittal values to understand their potential role in the disease process, and to promote spinopelvic balance at surgery. In this article, we provide a comprehensive review of the literature regarding the implications of abnormal spinopelvic parameters and discuss surgical strategies for correction of sagittal balance. Additionally, the authors rate and critique the quality of the literature cited in a systematic review approach to give the reader an estimate of the veracity of the conclusions reached from these reports.

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Implications of Spinopelvic Alignment for the Spine Surgeon

Neurosurgery ◽

10.1227/01.neu.0000462077.50830.1a ◽

2011 ◽

Vol 76 (suppl_1) ◽

pp. S42-S56 ◽

Cited By ~ 29

Author(s):

Vivek A. Mehta ◽

Anubhav Amin ◽

Ibrahim Omeis ◽

Ziya L. Gokaslan ◽

Oren N. Gottfried

Keyword(s):

Sagittal Balance ◽

Lumbar Lordosis ◽

Pelvic Incidence ◽

Degenerative Spondylolisthesis ◽

Disease Process ◽

Sacral Slope ◽

Sagittal Imbalance ◽

Spinopelvic Parameters ◽

Spinopelvic Alignment ◽

Spinopelvic Balance

Abstract The relation of the pelvis to the spine has previously been overlooked as a contributor to sagittal balance. However, it is now recognized that spinopelvic alignment is important to maintain an energy-efficient posture in normal and disease states. The pelvis is characterized by an important anatomic landmark, the pelvic incidence (PI). The PI does not change after adolescence, and it directly influences pelvic alignment, including the parameters of pelvic tilt (PT) and sacral slope (SS) (PI = PT 1 SS), overall sagittal spinal balance, and lumbar lordosis. In the setting of an elevated PI, the spineadapts with increased lumbar lordosis. To prevent or limit sagittal imbalance, the spine may also compensate with increased PT or pelvic retroversion to attempt to maintain anupright posture. Abnormal spinopelvic parameters contribute to multiple spinal conditions including isthmic spondylolysis, degenerative spondylolisthesis, deformity, and impact outcome after spinal fusion. Sagittal balance, pelvic incidence, and all spinopelvic parameters are easily and reliably measured on standing, full-spine (lateral) radiographs, and it is essential to accurately assess and measure these sagittal values to understand their potential role in the disease process, and to promote spinopelvic balance at surgery. In this article, we provide a comprehensive review of the literature regarding the implications of abnormal spinopelvic parameters and discuss surgical strategies for correction of sagittal balance. Additionally, the authors rate and critique the quality of the literature cited in a systematic review approach to give the reader an estimate of the veracity of the conclusions reached from these reports.

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Conflicting calculations of pelvic incidence and pelvic tilt secondary to transitional lumbosacral anatomy (lumbarization of S-1): case report

Journal of Neurosurgery Spine ◽

10.3171/2016.5.spine16196 ◽

2017 ◽

Vol 26 (1) ◽

pp. 45-49 ◽

Cited By ~ 4

Author(s):

Charles H. Crawford ◽

Steven D. Glassman ◽

Jeffrey L. Gum ◽

Leah Y. Carreon

Keyword(s):

Sagittal Balance ◽

Lumbar Lordosis ◽

Pelvic Incidence ◽

Adult Spinal Deformity ◽

Accurate Identification ◽

Current Case ◽

Pelvic Parameters ◽

Radiology Reports ◽

Sagittal Malalignment

Advancements in the understanding of adult spinal deformity have led to a greater awareness of the role of the pelvis in maintaining sagittal balance and alignment. Pelvic incidence has emerged as a key radiographic measure and should closely match lumbar lordosis. As proper measurement of the pelvic incidence requires accurate identification of the S-1 endplate, lumbosacral transitional anatomy may lead to errors. The purpose of this study is to demonstrate how lumbosacral transitional anatomy may lead to errors in the measurement of pelvic parameters. The current case highlights one of the potential complications that can be avoided with awareness. The authors report the case of a 61-year-old man who had undergone prior lumbar surgeries and then presented with symptomatic lumbar stenosis and sagittal malalignment. Radiographs showed a lumbarized S-1. Prior numbering of the segments in previous surgical and radiology reports led to a pelvic incidence calculation of 61°. Corrected numbering of the segments using the lumbarized S-1 endplate led to a pelvic incidence calculation of 48°. Without recognition of the lumbosacral anatomy, overcorrection of the lumbar lordosis might have led to negative sagittal balance and the propensity to develop proximal junction failure. This case illustrates that improper identification of lumbosacral transitional anatomy may lead to errors that could affect clinical outcome. Awareness of this potential error may help improve patient outcomes.

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Sagittal balance correction using anterior only motion preserving hybrid construct

The Spine Journal ◽

10.1016/j.spinee.2014.12.132 ◽

2015 ◽

Vol 15 (3) ◽

pp. S82-S83

Author(s):

Eyal Behrbalk ◽

Ofir Uri ◽

Peter Rehousek ◽

Bronek Boszczyk

Keyword(s):

Sagittal Balance ◽

Hybrid Construct ◽

Balance Correction

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