Abstract
The impact of sagittal plane alignment on the treatment of spinal disorders is of critical importance. A failure to recognise malalignment in this plane can have significant consequences for the patient not only in terms of pain and deformity, but also social interaction due to deficient forward gaze. A good understanding of the principles of sagittal balance is vital to achieve optimum outcomes when treating spinal disorders. Even when addressing problems in the coronal plane, an awareness of sagittal balance is necessary to avoid future complications. The normal spine has lordotic curves in the cephalad and caudal regions with a kyphotic curve in between. Overall, there is a positive correlation between thoracic kyphosis and lumbar lordosis. There are variations on the degree of normal curvature but nevertheless this shape allows equal distribution of forces across the spinal column. It is the disruption of this equilibrium by pathological processes or, as in most cases, ageing that results in deformity. This leads to adaptive changes in the pelvis and lower limbs. The effects of limb alignment on spinal posture are well documented. We now also know that changes in pelvic posture also affect spinal alignment. Sagittal malalignment presents as an exaggeration or deficiency of normal lordosis or kyphosis. Most cases seen in clinical practise are due to kyphotic deformity secondary to inflammatory, degenerative or post-traumatic disorders. They may also be secondary to infection or tumours. There is usually pain and functional disability along with concerns about self-image and social interaction due to inability to maintain a horizontal gaze. The resultant pelvic and lower limb posture is an attempt to restore normal alignment. Addressing this complex problem requires detailed expertise and awareness of the potential pitfalls surrounding its treatment.
Similar content being viewed by others
References
Berthonnaud E, Dimner J, Roussouly P, Labelle H (2004) Analysis of the sagittal balance of the spine and pelvis using shape and orientation parameters. J Spine Disord 18(1):40–47
Berven SH, Deviren V, Smith JA, Emami A, Hu SS, Bradford DS (2001) Management of fixed sagittal plane deformity: results of the transpedicular wedge resection osteotomy. Spine 26(18):2036–2043
Boachie-Adjei O, Bradford DS (1991) Vertebral column resection and arthrodesis for complex spinal deformities. J Spinal Disord 4(2):193–202
Boesker EH, Moe JH, Winter RB, Koop SE (2000) A determination of the normal thoracic kyphosis: a roentgenographic study of 121 normal children. J Pediatr Orthop 20:796–798
Bradford DS, Schumacher WL, Lonstein JE (1987) Ankylosing spondylitis: experience in surgical management of 21 patients. Spine 12:238–243
Bridwell KH, Bernhardt M (1989) Segmental Analysis of the sagittal plane alignment of the normal thoracic and lumbar spines and thoracolumbar junction. Spine 14:717–721
Bridwell KH, Lewis SJ, Edwards C, Lenke LG, Iffrig TM, Berra A (2003) Complications and outcomes of pedicle subtraction osteotomies for fixed sagittal imbalance. Spine 28(18):2093–2101
Bridwell KH, Lewis SJ, Lenke LG, Baldus C, Blanke K (2003) Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance. J Bone Joint Surg Am 85-A(3):454–463
Bridwell KH (2006) Decision making regarding Smith-Petersen vs pedicle subtraction osteotomy vs vertebral column resection for spinal deformity. Spine 31(19 suppl):S171–S178
Buchowski JM, Bridwell KH, Lenke LG, Kuhns CA (2007) Neurologic complications of lumbar pedicle subtraction osteotomy. Spine 32(20):2245–2252
Camargo FP, Cordeiro EN, Napoli MM (1986) Corrective osteotomy of the spine in ankylosing spondylitis. Experience with 66 cases. Clin Orthop 208:157–167
Chen IH, Chien JT, Yu TC (2001) Transpedicular wedge osteotomy for correction of thoracolumbar kyphosis in ankylosing spondylitis. Spine 26(16):354–360
Danisa OA, Turner D, Richardson WJ (2000) Surgical correction of lumbar kyphotic deformity: posterior reduction ‘eggshell’ osteotomy. J Neurosurg 92(1 suppl):50–56
During J, Goudfrooij H, Keesen W, Beeker TW, Crowe A (1985) Toward standards for posture: postural characteristics of the lower back system in normal and pathologic conditions. Spine 10(1):83–87
Djurasovic M, Glassman SD (2007) Correlation of radiographic and clinical findings in spinal deformities. Neurosurg Clin N Am 18(2):223–227
Fox MW, Onofrio BM, Kilgore JE (1993) Neurosurgical complications of ankylosing spondylitis. J Neurosurgery 78(6):871–878
Farcy JP, Schwab FJ (1997) Management of flatback and related kyphotic decompensation syndromes. Spine 22:2452–2457
Fisher PE, John JF (1994) Radiographic determination of the anatomic hip centre. a cadaver study. Acta Orthop Scand 65:509–510
Glassman SD, Bridwell K, Dimar JR, Horton W et al (2005) The impact of positive sagittal balance on adult spinal deformity. Spine 30(18):2024–2029
Hahn F, MD Min, Kan MD, Leonardi Massimo MD (2007) Lumbar spinal osteotomy for kyphosis in ankylosing spondylitis: the significance of the whole body kyphosis angle. J Spinal Disord Tech 20(2):149–153
Halm H, Metz-Stavenhagen P, Zielke K (1995) Results of surgical correction of kyphotic deformities of the spine in ankylosing spondylitis on the basis of the modified arthritis impact measurement scales. Spine 20(14):1612–1619
Hardacker JW, Shuford RF, Capicotto RN, Pryor PW (1997) Radiographic standing cervical segmental alignment in adult volunteers without neck symptoms. Spine 22:1472–1480
Hehne HJ, Zielke K, Bohm H (1990) Polysegmental lumbar osteotomies and transpedicular fixation for correction of long-curved kyphotic deformities in ankylosing spondylitis. Report on 177 cases. Clin Orthop 258:49–55
Horton WC, Brown CW, Bridwell KH (2005) The effect of arm position on sagittal plane alignment. Spine 30:427–433
Jackson RP, Peterson MD, McManus AC, Hales C (1998) Compensatory spinopelvic balance over the “hip axis” and better reliability in measuring lordosis to the pelvic radius on standing lateral radiographs of adult volunteers and patients. Spine 23:1750–1767
Jackson RP MD, Phipps T, Hales C, Suber J (2003) Pelvic lordosis and alignment in spondylolisthesis. Spine 28(2):151–160
Kim KT, Suk KS, Cho YJ, Hong GP, Park BJ (2002) Clinical outcome results of pedicle subtraction osteotomy in ankylosing spondylitis with kyphotic deformity. Spine 27(6):612–618
Kim YJ, Bridwell KH, Lenke LG, Cheh G, Baldus C (2007) Results of lumbar pedicle subtraction osteotomies for fixed sagittal imbalance: a minimum 5-year follow-up study. Spine 32(20):2189–2197
Kyn-Jung Cho MD, Keith Bridwell H, Lawrence G, Lenke MD, Annette Berra BA, Christy Baldus RN (2005) Comparison of Smith-Petersen versus pedicle subtraction osteotomy for the correction of fixed sagittal imbalance. Spine 30(18):2030–2037
La Grone MO, Loss of lumbar lordosis (1988) A complication of spinal fusion for scoliosis. Orthop Clin North Am 19:383–393
Legaye J, Duval-Beaupere G, Hecquet J, Marty C (1998) Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves. Eur Spine J 7(2):99–103
Lichtblau PO, Wilson PD (1956) Possible mechanism of aortic rupture in orthopaedic correction of rheumatoid spondylitis. J Bone Joint Surg Am 38(1):123–127
Mac-Thiong JM, Labelle H, Berthonnaud E, Betz RR, Roussouly P (2007) Sagittal spinopelvic balance in normal children and adolescents. Eur Spine J Feb 16(2):227–234
McMaster MJ (1985) A technique for lumbar spinal osteotomy in ankylosing spondylitis. J Bone Joint Surg Br 67(2):204–210
McMaster MJ, Coventry MB (1973) Spinal osteotomy in ankylosing spondylitis. Technique, complications, and long-term results. Mayo Clin Proc 48(7):476–486
Noun Z, Lapresle P, Missenard G (2000) Posterior lumbar osteotomy for flatback in adults. J Spinal Disord 14:311–316
Pile KD, Laurent MR, Salmond CE, Best MJ, Pyle EA, Moloney RO (1991) Clinical assessment of ankylosing spondylitis: a study of observer variation in spinal measurements. Br J Rheumatol 30(1):29–34
Roussouly P, Gollogly S, Berthonnaud E, Dimnet J (2005) Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine 30(3):346–353
Roussouly P, Richard A, Vallese P, Berthonnaud E (2000) Compared effect of eggshell transpedicular lumbar osteotomy and pelvic osteotomy in correction of great sagittal imbalance. 9th International Meeting on Advanced Spine Techniques, Montreux, Switzerland
Schwab F, Lafage V, Patel A, Farcy JP (2009) Sagittal plane considerations and the pelvis in the adult patient. Spine 34(17):1828–1833
Scoliosis Research Society. White paper on sagittal plane alignment
Simmons EH (1994) Relation of vascular complications to the level of lumbar extension osteotomy in ankylosing spondylitis. 61st Annual meeting of the American academy of Orthopaedic Surgeons, New Orleans
Simmons EH (1977) Kyphotic deformity of the spine in ankylosing spondylitis. Clin Orthop 128:65–77
Smith-Petersen MN, Larson CB, Aufranc OE (1945) Osteotomy of the spine for correction of flexion deformity in rheumatoid arthritis. J Bone Joint Surg Am 27:1–11
Suk KS, Kim KT, Lee SH, Kim JM (2003) Significance of chin-brow vertical angle in correction of kyphotic deformity of ankylosing spondylitis patients. Spine 28(17):2001–2005
Thomasen E (1985) Vertebral osteotomy for correction of kyphosis in ankylosing spondylitis. Clin Orthop 194:142–152
Van Royen BJ, De Gast A (1999) Lumbar osteotomy for correction of thoracolumbar kyphotic deformity in ankylosing spondylitis. A structured review of three methods of treatment. Ann Rheum Dis 58(7):399–406
Van Royen BJ, De Gast A, Smit TH (2000) Deformity planning for sagittal plane corrective osteotomies of the spine in ankylosing spondylitis. Eur Spine J 9(6):492–498
Van Royen BJ, Slot GH (1995) Closing-wedge posterior osteotomy for ankylosing spondylitis. Partial corpectomy and transpedicular fixation in 22 cases. J Bone Joint Surg Br 77(1):117–121
Van Royen BJ, Toussaint HM, Kingma I, Bot SD, Caspers M, Harlaar J, Wuisman PI (1998) Accuracy of the sagittal vertical axis in a standing lateral radiograph as a measurement of balance in spinal deformities. Eur Spine J 7(5):408–412
Vaz G, Roussouly P, Berthonnaud E, Dimnet J (2000) Sagittal morphology and equilibrium of pelvis and spine. Eur Spine J 11:80–87
Voutsinas SA, MacEwen GD (1986) Sagittal profiles of the spine. Clinical Orthopaedics and related research 210:235–242
Weatherley C, Jaffray D, Terry A (1988) Vascular complications associated with osteotomy in ankylosing spondylitis: a report of two cases. Spine 13(1):43–46
Willems KF, Slot GH, Anderson PG, Pavlov PW, de Kleuver M (2005) Spinal osteotomy in patients with ankylosing spondylitis: complications during first post operative year. Spine 30(1):101–107
Vendatam R, Lenke LG, Keeney JA, Bridwell KH (1998) Comparison of standing sagittal spinal alignment in asymptomatic adolescents and adults. Spine 23(2):211–215
Acknowledgment
The authors would like to thank Mr. Sanjay Purushothamdas and Dr Akash Sharma of the Spinal Surgery Unit, Nuffield Orthopaedic Centre, Oxford for proof reading and organisation of the manuscript.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Roussouly, P., Nnadi, C. Sagittal plane deformity: an overview of interpretation and management. Eur Spine J 19, 1824–1836 (2010). https://doi.org/10.1007/s00586-010-1476-9
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00586-010-1476-9