CHAPTER

SAGITTAL IMBALANCE
21
Claudia Ottardi*, Andrea Luca†, Fabio Galbusera†
Politecnico di Milano, Milan, Italy* IRCCS Galeazzi Orthopedic Institute, Milan, Italy†

­THE GLOBAL ALIGNMENT AND THE SPINO-PELVIC PARAMETERS

In healthy individuals, the spine is straight in the coronal plane, whereas it exhibits an S-shape in
the sagittal plane. The combination the regional curvatures allows keeping the standing posture with
minimal energy consumption (Le Huec et al., 2011b). Indeed, the vertical projection of the center of
gravity of the trunk passes through the sacrum; the curved sagittal profile of the spine contributes to
this equilibrium condition by avoiding buckling under gravity load. The basis of the cervical spine, that
is, the C7 vertebra, is used clinically to measure a parameter to describe the global spine alignment, the
sagittal vertical axis (SVA), defined as the distance in the horizontal direction between the plumb line
conducted from the center of C7 to the posterosuperior corner of the sacral endplate (Fig. 1) (Jackson
and McManus, 1994). In an ideal spinal alignment, SVA should be very low; a positive value (i.e., the
plumb line more anterior than the sacral landmark) of 5 cm has been suggested as a threshold for spinal
misalignment (Jackson and McManus, 1994). SVA is commonly used in the clinical setting to easily
describe the spinal alignment with a single value; however, it should be noted that SVA is dependent
on the posture, and compensatory mechanisms may reduce its value even in subjects with alignment
disorders.
In recent years, an approach emerged to characterize the global alignment of the spine starting from
anatomical parameters that describe the pelvis emerged, and the approach has gained a general consen-
sus. The key element of the approach is the pelvic incidence (PI) (Fig. 2), which is the angle measured
in a sagittal projection between the line connecting the center of the femoral head to the center of the S1
endplate and the line orthogonal to the same endplate (Duval-Beaupere et al., 1992). This parameter is
by definition purely morphological, because it does not vary when the hip joints are flexed or extended
and is therefore commonly used to concisely describe the shape of the pelvis of each patient (Legaye
et al., 1998). It should, however, be noted that several studies showed that the value of this parameter
is not constant throughout life, but changes slightly during infancy and adolescence (Mangione et al.,
1997; Mac-Thiong et al., 2004). Studies showed that the PI ranges between 35 degree and 85 degree
and has an average value in asymptomatic adult subjects of 52 degree (Vialle et al., 2005).
PI is normally complemented by two other angles, the sacral slope (SS) and the pelvic tilt (PT),
which are not morphological parameters but depend on the pelvis orientation. SS is defined as the angle
between the sagittal projection of the S1 endplate and the horizontal line, whereas PT is defined as the
angle between the vertical line and the line connecting the center of the S1 endplate and the center of
the femoral heads. The values of the three parameters are interdependent:

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© 2018 Elsevier Ltd. All rights reserved.
379
380 CHAPTER 21  SAGITTAL IMBALANCE

FIG. 1
Sagittal vertical axis (SVA) in a healthy subject (left) and in an imbalanced subject (right). SVA is defined as the
distance between the posterior margin of the S1 endplate and the C7 plumb line.

FIG. 2
Geometrical definitions of the pelvic incidence (PI), sacral slope (SS), and pelvic tilt (PT).

PI = PT + SS
Indeed, if the pelvis is retroverted, SS decreases and PT increases, and their sum remains constant
and dependent on the pelvic morphology.
There is a general consensus that the value of PI is one of the main determinants of the global spine
alignment (Legaye et al., 1998; Vialle et al., 2005). Arguably, patients with a high PI will also tend to
 ­THE GLOBAL ALIGNMENT AND THE SPINO-PELVIC PARAMETERS 381

have a high SS and PT; indeed, it has been shown that SS increases more than PT, and a high PI will
therefore dictate a higher slope of the sacral endplate (Vialle et al., 2005). In order to keep a correct
global alignment of the head over the sacrum (i.e., a low SVA), a pronounced lumbar lordosis will be
necessary. The chain of correlation has also been shown to propagate to the thoracic and cervical re-
gions, even with lower, or lack of, statistical significance (Ames et al., 2013b).
Roussouly and colleagues introduced a classification system for the alignment of the lumbosacral
spine that described its normal variability in the adult asymptomatic population and that is commonly
used today (Roussouly et al., 2005). The system is based on four radiological parameters: (i) SS, (ii)
the positions of the apex of the lumbar lordosis, (iii) the inflection point between kyphosis and lordosis,
and (iv) the lordosis tilt angle (defined between the vertical line and that connecting the inflection point
and the anterior corner of the sacral endplate). The authors defined four categories to classify the spines
of 160 asymptomatic volunteers (Fig. 3). They found that in type 1, a low SS as well as a short lordosis
(low inflection point) determined a kyphotic curvature in the proximal lumbar spine, which propagated
to the thoracic region. Subjects showing a type 2 alignment also had a low SS, but combined with a
longer, flatter lordosis that generally gave a hypolordotic and hypokyphotic appearance to the spine. In
type 3, SS ranged between 35 degree and 45 degree, and the inflection point reached L1, resulting in
a harmonious spinal shape. Type 3 spines were found to be the most common types in the cohort (60
subjects). In type 4, SS was higher than 45 degree, generally because of a high PI. Also, both lumbar
lordosis and thoracic kyphosis were pronounced for this type.
The strong correlation between PI and lumbar lordosis led to the widespread use of the former
value, which can be easily measured on sagittal X-rays images, to determine the target lordosis to
be achieved in the surgical treatment of sagittal spinal misalignment. Indeed, Schwab and colleagues
suggested that if the difference between PI and lumbar lordosis (PI-LL) is around 10 degree after sur-
gical correction, a correct alignment is achieved benefiting the clinical outcome (Schwab et al., 2010;
Schwab et al., 2013). However, the general validity of such a simple approach has been questioned;

FIG. 3
The Roussouly classification of the physiological spinopelvic organization, based on the sacral slope (SS), the
position of the apex and the inflection point, and the lordosis angles. In type 1, a low SS as well as a short
lordosis are observable. In type 2, a longer, lower lordosis gives the spine a flatter appearance. In type 3, the
spinal shape is harmonious. In type 4, both lumbar lordosis and thoracic kyphosis are pronounced.
382 CHAPTER 21  SAGITTAL IMBALANCE

patients with a high PI might require a smaller lumbar lordosis, and a pronounced thoracic kyphosis
might need to be counterbalanced by a lower lordosis even in the case of a high PI (Schwab et al.,
2014a). Nevertheless, it is generally believed that a target value of PI-LL around 10 degree is a good
starting point when planning a surgical correction of the sagittal spine profile.

­ GING AND PATHOLOGICAL CHANGES IN THE SAGITTAL ALIGNMENT

A
AND COMPENSATORY MECHANISMS
In the course of the aging process, changes that alter the spine alignment may occur, such as degenera-
tive disc disease, which generally leads to a loss of the lumbar lordosis and thoracic hyperkyphosis.
Both these changes induce a forward shift of the trunk and a higher activation of the trunk muscles in
order to maintain an erect posture. To keep the energy expenditure to a minimum and to reach an ergo-
nomic posture, several compensation mechanisms, which might be active individually or in combina-
tion, are actuated to return the body’s gravity line close to the feet. If the compensation mechanisms are
effective and the patient can reach a satisfactory and nonsymptomatic posture and gait even in presence
of loss of lordosis or hyperkyphosis (i.e., a small value of SVA), the spine alignment is categorized as
“compensated imbalance” and in most cases does not require surgical treatment (Diebo et al., 2015).
An effective compensation mechanism is pelvic retroversion (Barrey et  al., 2011; Barrey et  al.,
2007; Jackson et al., 1998). By rotating the pelvis backward (i.e., decreasing SS and increasing PT),
the gravity line is shifted backward, and SVA is reduced. Indeed, some degrees of pelvic retroversion
is observable in most elderly subjects, even asymptomatic ones (Jackson et al., 1998). This mechanism
may be less effective in subjects with low PI, because their hip joints are in a more extended position in
the standing posture, and therefore their range of motion in extension is more limited (Fig. 4).

FIG. 4
Degenerative changes may lead to a forward shift of the trunk and a higher activation of the trunk muscles in
order to maintain the erect posture (imbalance). Compensation mechanisms such as pelvic retroversion, loss
of thoracic kyphosis, segmental lumbar hyperextension, and retrolisthesis may help in regaining an ergonomic
posture.
 ­AGING AND PATHOLOGICAL CHANGES 383

FIG. 5
Knee flexion can act as a compensatory mechanism in imbalanced subjects. The pelvic shift, defined as the
distance between the sacrum plumb line and the ankle, is indicated by the arrow and is used to describe the
combined action of pelvic retroversion and knee flexion.

As the imbalance increases and pelvic retroversion alone is not able to cope with the misalignment,
other compensation mechanisms are recruited. The lumbar spine may increase its lordosis in the non-
degenerated segments, which undergo hyperextension and in some cases retrolisthesis (Barrey et al.,
2011; Jackson et al., 1998). This mechanism may, however, induce symptoms related to the overload
of the posterior elements and stenosis of the spinal canal. In younger subjects with a flexible spine, the
thoracic kyphosis may decrease, resulting in a generally flat sagittal profile, similar to the type 2 align-
ment in the Roussouly classification (Barrey et al., 2011; Barrey et al., 2007).
In severe cases, the lower limbs contribute to the chain of compensation (Fig.  5). Many elderly
subjects adopt a standing posture in which the knees are flexed, which allows for a higher range for the
realignment of the pelvis and therefore an effective compensation for the loss of lordosis or hyperky-
phosis (Obeid et al., 2011). Ankle extension is also commonly observable in such patients. However,
maintaining such a posture requires the activation of the quadriceps, gluteus maximus, and medius and
is thus tiresome; the gait may be impaired and exhausting as well. The resulting combination of pelvic
retroversion and knee flexion is commonly described by a single radiological parameter, the pelvic
shift, which represents the position of the pelvis with respect to the feet (Schwab et al., 2006).
It should be noted that sagittal imbalance may also be initiated by a knee degenerative pathology
with reduced range of motion in extension, which forces a neutral posture with flexed knees and lumbar
flattening as a compensation mechanisms (Murata et al., 2003). However, in elderly patients showing
multiple degenerative disorders, it may be difficult to determine which is the primary cause of the mis-
alignment, and planning of the treatment may not be straightforward.
384 CHAPTER 21  SAGITTAL IMBALANCE

­SURGICAL TREATMENT OF SAGITTAL IMBALANCE

Several studies reported a significant correlation between non-compensated sagittal imbalance and
a decrease in the quality of life of the affected subject (Schwab et al., 2008; Glassman et al., 2005a;
Glassman et al., 2005b). On the other hand, a successful surgical restoration of a correct sagittal align-
ment was linked to an improvement of patients’ health. These studies therefore support the concept of
realigning the spine by means of a surgical intervention, as well as of taking into account the sagittal
alignment of the spine when surgery is needed for the treatment of other spinal disorders. For example,
in planning the surgical correction of scoliosis, a correct sagittal alignment is currently considered of
utmost importance (Ilharreborde et al., 2014).
The surgical correction of sagittal imbalance is based on posterior instrumentation of the spine with
pedicle screws and rods. In the case of flexible curves, instrumentation alone that is eventually supple-
mented with anterior or posterior decompression and release is generally sufficient, whereas for stiff
deformities, the use of osteotomies needs to be considered (Savage and Patel, 2014). Therefore one of
the crucial steps in preoperative planning is to assess the flexibility of the deformity, which can be done
by means of supine X-rays with fulcrums or bolsters, as well as with CT or MRI scans. With the latter
two imaging methods, the condition of the intervertebral discs and the possible presence of osteophytes
or ankylosis, which increase the spinal stiffness, can be assessed (Savage and Patel, 2014).
A precise preoperative plan based on lateral X-rays taken in a standing posture is currently considered
mandatory before surgical correction of sagittal imbalance. First, radiographic parameters such as PI, SVA,
lumbar lordosis, and thoracic kyphosis are measured on the image, either manually or with the assistance
of a computer program (Lafage et al., 2015). These values are used to conduct an evaluation of the standing
posture of the patient, including the possible presence of compensatory mechanisms. Because the degen-
erative loss of lumbar lordosis is a common driver of sagittal imbalance, its evaluation is critical and is usu-
ally performed by calculating the PI − LL angle. As previously mentioned, a restoration of PI − LL lower
than 10 degree (typically 9 degree) is commonly considered as a desirable target after surgery. Therefore
the target LL can be calculated as LL = PI − 9 (Savage and Patel, 2014; Schwab et al., 2010).
Successful restoration of the sagittal balance should also take into account the compensatory mech-
anisms and should be aimed at minimizing them (Lafage et al., 2015). Pelvic retroversion is assessed
by evaluating PT, which increases when this compensation mechanism is active. A value of PT lower
than 20 degree is commonly assumed as a target for the surgery (Schwab et al., 2010). In addition,
TK is measured to evaluate a possible loss of kyphosis; knee flexion is also assessed if a whole body
X-ray image is available. The majority of spine surgeons accept the general rule that, after a success-
ful surgery, SVA should be lower than 5 cm (Schwab et al., 2010). It should be noted that other, more
sophisticated rules about preoperative planning have been presented and are currently in wide use. For
example, the full body integrated (FBI) method (Le Huec et al., 2011a) is widely used and well ac-
cepted by the medical community.

­VERTEBRAL OSTEOTOMIES
The correction of nonflexible deformities is commonly performed by means of vertebral osteotomies.
Depending on the patienťs age and condition, the type of deformity, and the surgeon’s experience, sev-
eral surgical techniques can be used and different outcomes can be reached. Recently, an anatomical
 ­VERTEBRAL OSTEOTOMIES 385

FIG. 6
Schematic representation of the most common osteotomies. From left to right: Ponte osteotomy (PO), Smith-
Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO), and vertebral column resection (VCR).

classification of spinal osteotomies was proposed in order to standardize the description of the surgical
interventions (Schwab et al., 2014b). Six grades of osteotomies were identified, which corresponded
to different resected regions and to increasing destabilization of the spine: (1) partial and (2) complete
facet joint removal; (3) partial and (4) complete pedicle and body resection (in some cases involving
also the disc); (5) complete resection of one vertebra and the disc; and (6) removal of multiple verte-
brae and discs. However, the surgical techniques most commonly employed are (Schwab et al., 2014b;
Bergin et al., 2010; Bridwell, 2006) (Fig. 6) as follows:
• Ponte osteotomy (PO): Originally developed in 1984 to treat Scheuermann kyphosis (Ponte
et al., 1984), this technique is performed by creating a posterior closing wedge on the articular
processes of adjacent vertebrae, leading to a 5- to 15-degree correction. It is commonly
performed on multiple levels.
• Smith-Petersen osteotomy (SPO): First described in 1969 (Smith-Petersen et al., 1969) and used
to treat ankylosis spondylitis or Scheuermann kyphosis, this technique involves both the anterior
and posterior columns. It allows for a correction up to 15 degree by shortening the posterior
column and opening the anterior one.
• Pedicle subtraction osteotomy (PSO): First described in 1985 (Thomasen, 1985), this technique
is now the most commonly used one for the treatment of fixed sagittal imbalance. It is a posterior
closing wedge technique that achieves higher degree of correction in a single level than the other
techniques achieve (up to 35 degree more). A single PSO can be an alternative to two or three SPOs.
• Vertebral column resection (VCR): This technique provides a very high degree of correction (up
to 60 degree) by complete removal of one vertebra and the discs above and below it (Lenke et al.,
2010). It is used only in severe cases and by expert hands and is associated with high morbidity
and risk of complications.
386 CHAPTER 21  SAGITTAL IMBALANCE

FIG. 7
Example of pedicle subtraction osteotomy to correct sagittal imbalance. First row, from left to right: pre-
operative sagittal and coronal X-rays of the entire thoracolumbar spine as well as sagittal projection of the
lumbar spine showing a major misalignment with loss of lumbar lordosis and increased thoracic kyphosis.
Second row: postoperative sagittal and coronal X-rays and lumbar sagittal CT showing the correction by means
of pedicle subtraction osteotomy at L4, posterior fixation from T4 to the sacroiliac joint with anterior support
through an interbody cage at L4–L5.

PSO is generally performed when other less invasive techniques are not sufficient to achieve the
targeted outcome (Berjano and Aebi, 2015). PSO is usually performed in the lumbar spine rather than
in the thoracic spine, although a few clinical studies have described use of PSO on the thoracic verte-
brae (Huang et al., 2015; Xia et al., 2017) (Fig. 7). Surgeons often prefer to operate on L2–L4 instead
of other segments, even though studies have shown that performing a PSO in the lower lumbar spine
 ­BIOMECHANICAL STUDIES OF SAGITTAL IMBALANCE AND REALIGNMENT 387

FIG. 8
Analysis of a retrieved rod broken at the level of a pedicle subtraction osteotomy. From left to right: (1)
anteroposterior X-rays of the patient, showing both rods broken at the osteotomy site (the circle indicates the
retrieved rod); (2) the rod superimposed to the lateral X-rays; (3) a confocal microscopy image of the fracture
surface; (4) a height map of the fracture surface, showing a typical fatigue failure initiated on the posterior
side. “A” indicates the anterior side, “P” the posterior one, “L” lateral, and “M” medial.

may have a higher risk of complications (Bridwell, 2006). Several surgeons perform the surgery on L4
whenever possible (Berjano and Aebi, 2015). It has been shown that PSO is linked to a non-negligible
risk of major complications (e.g., excessive blood loss, hardware failure, neurological and motor defi-
cits, cardiovascular problems, and infections), and minor complications (superficial infection, radicular
pain, and sensory deficiency) were found in up to 90% of cases (Ames et al., 2013a). Hardware failure,
typically rod breakage at the osteotomy level, is also very common (up to 39% of cases), thus making
PSO a challenging operation from a biomechanical point of view (Enercan et al., 2013) (Fig. 8).

­BIOMECHANICAL STUDIES OF SAGITTAL IMBALANCE AND REALIGNMENT

Most of the current knowledge about the sagittal alignment of the spine is based on clinical experi-
ence, that is, analysis of images of patients taken preoperatively, postoperatively, and at follow-up, as
well as on the investigation of the clinical outcomes and complications. Bioengineering methods such
as finite element modeling have been used in only a few studies. Keller and colleagues used a simple
numerical model to study the relationship between sagittal alignment and spinal loads based on X-ray
images of asymptomatic young subjects. They found that both compressive and shear spinal loads were
strongly influenced by the sagittal parameters. Galbusera and colleagues built a more sophisticated fi-
nite element model that also included the trunk muscles and that quantified the correlations between the
spinal loads and radiological parameters, such as LL and type following the Roussouly classification
(Galbusera et al., 2013; Galbusera et al., 2014). Nevertheless, fundamental aspects such as the validity
of the surgical targets (SVA less than 5 cm, PI − LL less than 10 degree, PT less than 20 degree) have
never been investigated from a biomechanical point of view.
Despite the high clinical interest in the correction of sagittal imbalance, including the critical as-
pects related to instrumentation failure, only a few published biomechanical and computational studies
have focused on the correction of sagittal imbalance. However, the related techniques are relatively
new, and their mid-to-long-term clinical outcomes and complications have been available for only a
few years. PO and discectomy were compared in a cadaveric study on the thoracic spine; this study
388 CHAPTER 21  SAGITTAL IMBALANCE

looked at the ROM and the translations of the treated vertebrae with respect to the intact one (Wang
et al., 2015). In another study, also on the thoracic spine, sequential POs were performed, and the flex-
ibility of the spine was measured after each resection (Sangiorgio et al., 2013). A recent study focused
on the effect of PSO and vertebral column resection (reduction of one or more motion segments) on
spinal cord tension and dural buckling. The authors found that with both techniques the spinal cord ten-
sion can be significantly decreased but that the reduction of the spinal height causes dural buckling that
can lead to compression of the neural structures (Safain et al., 2015). An interesting in vitro study was
performed with the goal of comparing the stiffness and fatigue life of fixation constructs used to per-
form PSO, with or without interbody cages above and below the osteotomy site (Deviren et al., 2012).
The authors performed a PSO at L3 on human specimens, followed by instrumentation with titanium
polyaxial screws (6.0 × 45 mm) and Cr-Co rods with a diameter of 5.5 mm. In half of the specimens, an
XLIF cage was inserted at the L2–L3 and L3–L4 levels. Then the authors tested the specimens by per-
forming a multidirectional bending test and found that the anterior support can increase the construct
rigidity. Consequently, they suggested using interbody cages associated with posterior fixation in order
to avoid the need for revision surgeries. In another cadaver study, the stiffness of various configurations
of devices used in the revision of PSOs were compared (Scheer et al., 2011). The use of supplemen-
tary rods at the osteotomy level was investigated on cadaveric specimens by Hallager and colleagues
(Hallager et al., 2016), who found that the four-rod construct was effective in reducing the strains in the
instrumentation, with a possible positive effect on the risk of rod fracture.
Concerning computational studies, Hato and colleagues studied a closing-opening correction os-
teotomy with a numerical model of the thoracolumbar spine, creating various models, varying the
kyphotic angle, and considering different degree of osteoporosis (Hato et  al., 2007). Charosky and
colleagues developed a simplified model in order to reproduce a PSO on L4 (with three defect situa-
tions) and study loads and stresses in different configurations of spinal implants (Charosky et al., 2014).
Ottardi and colleagues built a finite element model to investigate the effect of PSO without instrumen-
tation (Ottardi et al., 2016), which was found to be major in all motion directions as well as greater if
PSO was performed at L4 rather than at L3. The model was subsequently modified to study the effect of
instrumentation, namely posterior fixation and fixation with supplementary rods at the level of osteot-
omy (Luca et al., 2017). Results indicated that stiffer configurations (double rods and rods with higher
diameter) induced a marked reduction of the stresses on the instrumentation, but might slow down
healing at the osteotomy site because of the decreased load transferred through the anterior column.

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