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Kawai M, Yagi M, Okubo T, Ozaki M, Suzuki S, Takahashi Y, Tsuji O, Nagoshi N, Matsumoto M, Nakamura M, Watanabe K. The Effect of Age-Adjusted Sagittal Alignment on the Result of Posterior Decompression Surgery for Lumbar Spinal Canal Stenosis. Spine (Phila Pa 1976) 2024; 49:1004-1011. [PMID: 37755383 DOI: 10.1097/brs.0000000000004836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 09/13/2023] [Indexed: 09/28/2023]
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE The aim of this study was to compare the outcomes of posterior decompression surgery for lumbar spinal canal stenosis (LSS) in patients with preoperative sagittal malalignment (MA) with those without, after adjusting for age and sex. SUMMARY OF BACKGROUND DATA Sagittal balance is an important factor in spine surgery and is thought to affect postoperative outcomes after LSS. However, the relationship between sagittal MA and postoperative outcomes has not been thoroughly examined. PATIENTS AND METHODS We included 533 patients who underwent surgical treatment for LSS and also achieved 2-year follow-up. Patients were categorized into either an MA+ group (69 patients) or a matched-alignment (MA-) group (348 patients) based on age-adjusted preoperative sagittal alignment. We compared the baseline and 2-year postoperative health-related quality of life (HRQOL) using the Visual Analog Scale and Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) scores. We also calculated clinical efficacy using the minimal clinically important difference based on JOABPEQ scores, and age and sex-adjusted JOABPEQ scores 2 years after surgery. Differences between groups were examined using the Mann-Whitney U test and χ 2 analysis, where applicable. RESULTS Both groups showed an improved HRQOL after decompression surgery. Similar proportions of patients showed substantial improvement, as estimated by the minimal clinically important difference, in 4 out of 5 subdomains of the JOABPEQ. A significantly smaller proportion of patients in the MA+ group showed substantial improvement in lumbar function. The age and sex-adjusted HRQOL scores 2 years after surgery were lower in the MA+ group, particularly in the lumbar function and social life function subdomains of the JOABPEQ. CONCLUSION The effects of posterior decompression surgery alone can still be observed at least 2 years postoperatively for patients with LSS and concomitant sagittal MA. Patients with sagittal MA may experience lower HRQOL than those without this type of MA.
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Affiliation(s)
- Momotaro Kawai
- Department of Orthopedic Surgery, School of Medicine, Keio University, Tokyo, Japan
- Department of Orthopedic Surgery, Spine Center, Kitasato Institute Hospital, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Mitsuru Yagi
- Department of Orthopedic Surgery, School of Medicine, Keio University, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Toshiki Okubo
- Department of Orthopedic Surgery, School of Medicine, Keio University, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Masahiro Ozaki
- Department of Orthopedic Surgery, School of Medicine, Keio University, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Satoshi Suzuki
- Department of Orthopedic Surgery, School of Medicine, Keio University, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Yohei Takahashi
- Department of Orthopedic Surgery, School of Medicine, Keio University, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Osahiko Tsuji
- Department of Orthopedic Surgery, School of Medicine, Keio University, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Narihito Nagoshi
- Department of Orthopedic Surgery, School of Medicine, Keio University, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopedic Surgery, School of Medicine, Keio University, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopedic Surgery, School of Medicine, Keio University, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Kota Watanabe
- Department of Orthopedic Surgery, School of Medicine, Keio University, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
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Hey HWD, Wong HK, Liu GKP, Tay HW, Sardar ZM, Hasegawa K, Riahi H, Bourret S, Cerpa M, Le Huec JC, Lenke LG. Morphological description of sagittal lumbar spinal alignment using curve magnitude, span, and apex-the multiethnic alignment normative study (MEANS). Spine J 2023; 23:1709-1720. [PMID: 37442208 DOI: 10.1016/j.spinee.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 06/20/2023] [Accepted: 07/01/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND CONTEXT Current definition of lumbar lordosis uses the L1-S1 angle. Prevailing classification of sagittal spinal morphology, derived from a young adult population, classifies the spine into four subtypes defined by their sacral slope (SS) and curve morphology. PURPOSE To describe physiological sagittal alignment of the lumbar spine across age groups using three main parameters that dictate the lumbar curve: angular magnitude, span, and apex. STUDY DESIGN A large, multicenter, cross-sectional radiographic comparison study. PATIENT SAMPLE Four hundred sixty-eight healthy, asymptomatic subjects aged 18 to 80 years from five countries (184 males, 284 females; 98 France, 119 Japan, 79 Singapore, 80 Tunisia, 92 USA, mean age 40.61±14.99 years). OUTCOME MEASURES Sagittal lumbar profile subtypes clustered based on lumbar curve angular magnitude (ie, Cobb angle of the lumbar lordosis), span, and apex, and described by sagittal radiographic parameters. METHODS Subjects underwent whole-body low-dose EOS stereoradiographs. Comparisons between conventional L1-S1 lumbar lordosis (cLL) and true lumbar lordosis (tLL, defined by the inflection-S1 angle) were conducted. Using the K-means clustering algorithm, lumbar curve angular magnitude, span and apex were used to classify sagittal spinal morphology into subtypes, stratified across age groups. Further univariate and multivariate analyses were conducted to compare radiographic parameters across subtypes, and identify predictors for the lumbar curve's angular magnitude, span and apex. RESULTS Mean cLL was -57.27±11.37°, and tLL was -62.62±10.76°. Using tLL, instead of cLL, to describe sagittal spinal morphology, we found significant differences in terms of angular magnitude of the lumbar curve, the median thoracolumbar inflection vertebral level and pelvic incidence-lumbar lordosis mismatch Multivariate analysis found a larger SS, more positive T9 tilt, and more kyphotic T4-T12 predictive for a more lordotic tLL, while a larger overhang distance predicted for a less lordotic tLL (p-values<.001). In addition, a larger T9 tilt, less lordotic L1-L5 and smaller PT were predictors of a more caudal thoracolumbar inflection and lumbar apical vertebral levels (p-values<.001). Sagittal lumbar profiles of subjects age<30 years, 30≤age<60 years and age≥60 years, could be classified into 4, 6, and 3 subtypes, respectively. CONCLUSIONS Sagittal lumbar profile subtypes vary across age groups, with more homogenous morphologies at the extremes of ages. Improved understanding of the morphological evolution of sagittal spinal profiles with age in asymptomatic individuals will help guide future individualized surgical treatment.
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Affiliation(s)
- Hwee Weng Dennis Hey
- Department of Orthopaedic Surgery, National University Health System, Singapore.
| | - Hee-Kit Wong
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Gabriel Ka-Po Liu
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Hui Wen Tay
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Zeeshan M Sardar
- Department of Orthopedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, USA
| | - Kazuhiro Hasegawa
- Department of Orthopaedic Surgery, Niigata University School of Medicine, Niigata City, Japan
| | - Hend Riahi
- Department of Orthopaedic Surgery, Institut Kassab D'orthopédie, Ksar Said La Manouba, Tunis, Tunisia
| | - Stéphane Bourret
- Department of Orthopaedic Surgery, Polyclinique Bordeaux nord Aquitaine, Bordeaux 33000, France
| | - Meghan Cerpa
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Jean-Charles Le Huec
- Department of Orthopaedic Surgery, Polyclinique Bordeaux nord Aquitaine, Bordeaux 33000, France
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
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Park JY, Cho BW, Kwon HM, Park KK, Lee WS. Knee Extension Is Related to the Posteriorly Deviated Gravity Line to the Pelvis in Young Adults: Radiographic Analysis Using Low-Dose Biplanar X-ray. Yonsei Med J 2022; 63:933-940. [PMID: 36168246 PMCID: PMC9520046 DOI: 10.3349/ymj.2022.0184] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/19/2022] [Accepted: 08/14/2022] [Indexed: 11/28/2022] Open
Abstract
PURPOSE We sought to compare the radiographic parameters concerning the sagittal alignment of the standing whole-body skeletons between the knee extension group and control group using the low-dose biplanar X-ray system in a young adult population without knee pain, and to investigate the associated variables for the sagittal knee angle (sagKA) among the radiographic parameters of global sagittal alignment. MATERIALS AND METHODS We reviewed whole-body standing sagittal radiographs of 124 young adults taken from December 2018 to May 2020 in a single institution. We compared the radiographic parameters concerning the lower extremity sagittal alignment and global sagittal alignment between the knee extension group and control group. The factors correlated with sagKA were evaluated using multiple linear regression analysis. RESULTS The sagittal vertical axis (SVA), the horizontal offset between the gravity line (GL) and the posterior edge of S1 endplate (GL-S), and the horizontal offset between the GL and the hip center (GL-H) were -11.6±21.3 mm, 5.1±23.8 mm, and -25.1±27.1 mm in the knee extension group, respectively, which were significantly smaller than those in the control group. The C7 plumb line (C7PL) and GL were deviated posterior to the sacrum and the hip center in the knee extension group, with the mean sagKA of -5.6° in young adults. CONCLUSION The GL-H using GL, not the SVA using C7PL, was a significant radiographic factor associated with the sagKA.
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Affiliation(s)
- Jun Young Park
- Department of Orthopedic Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Byung Woo Cho
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyuck Min Kwon
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kwan Kyu Park
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Woo-Suk Lee
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Hey HWD, Tan KLM, Lau ETC, Ng JWP, Liu GKP, Wong HK. The Impact of Radiographic Lower Limb-Spinal Length Proportion on Whole-Body Sagittal Alignment. Spine (Phila Pa 1976) 2022; 47:E38-E45. [PMID: 34882649 DOI: 10.1097/brs.0000000000004240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A radiographic comparative study. OBJECTIVE To investigate the influence of radiographic lower limb-spinal length proportion on sagittal radiographic parameters. SUMMARY OF BACKGROUND DATA Although lordotic realignment of the lumbar spine is a well-established surgical strategy, its ideal target has not been fully understood. The widely used pelvic incidence-lumbar lordosis discrepancy (PI-LL) method to guide lordotic restoration of the lumber spine in the standing posture, may be further refined using the novel, radiographic lower limb-spinal length proportion parameter in selected subjects. METHODS A 100 healthy subjects were imaged in the standing posture using EOS imaging to obtain whole-body lateral radiographs for the measurement of sagittal radiographic parameters. Univariate analyses were performed to compare radiographic parameters between groups with different radiographic lower limb-spinal length proportion. Multivariate analyses were performed to identify the associations between lower limb-spinal length proportions and other radiographic parameters. RESULTS Regardless of lower limb-spinal length proportion (mean = 1.4), global lumbar angle (GLA) differed from spinal lordosis (SL), with the absolute means of SL and GLA larger and smaller than pelvic incidence (PI) respectively. Univariate analysis showed that patients with proportionately larger lower limb-spinal length proportion are more likely to have larger mean T1-slope, global thoracic angle (GTA), spinal kyphosis (SK), GLA, and SL. Multivariate analysis showed that a larger lower limb length-spinal length proportion is predictive of larger GLA is less than -47.69° (Odds Ratio (OR) 2.660, P = 0.026), and larger T1-slope of more than 18.84° (OR 3.695, P = 0.012). CONCLUSION Larger radiographic lower limb-spinal length proportion results in naturally accentuated spinal curves. These patients balance with a larger lumbar lordosis that is closer to the PI and a higher T1-slope which should be considered for spinal realignment. SL differs from GLA and should be separately assessed.Level of Evidence: 3.
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Affiliation(s)
- Hwee Weng Dennis Hey
- Department of Orthopaedic Surgery, National University Health System (NUHS), Singapore
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Hey HWD, Lin S, Tay HW, Tay YJ, Liu GKP, Wong HK. Understanding "Kyphosis" and "Lordosis" for Sagittal Balancing in Two Common Standing Postures. Spine (Phila Pa 1976) 2021; 46:1603-1611. [PMID: 34747908 DOI: 10.1097/brs.0000000000004106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cross-sectional radiographic comparison study. OBJECTIVE The aim of this study was to understand whole-body balancing in directed and natural standing postures, through comparison of kypholordotic ratios on whole-body radiographs of young, healthy subjects. SUMMARY OF BACKGROUND DATA Recent studies highlighted the importance of understanding whole-body balancing, proposing the use of the more physiological natural standing posture, together with the conventional directed standing posture, for imaging. METHODS Sixty healthy, 21-year-old subjects (36 males, 24 females) were recruited. EOS whole-body radiographs of subjects in directed and natural standing postures were obtained. Radiographic parameters compared include C2-sagittal vertical axis (C2-SVA), C7-SVA, C2-7-SVA, global cervical angles (C0-T1 and C2-C7), regional cervical angles (C0-C2, C2-C4, C4-C7), T1-slope, global thoracic angles (T1-T12 and T1-inflection vertebra [Inf]), thoracolumbar angle (T11-L2), global lumbar angles (T12-S1 and Inf-S1), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), spinocoxa angle (SCA), and femoral alignment angle (FAA). Kypholordotic ratios of T1-12/T12-S1, T1-Inf/Inf-S1, Tl-Inf/SCA, and (T1-Inf + FAA)/(T1-slope + SCA) were calculated and compared. RESULTS Compared to directed standing, natural standing has greater C2-SVA and C7-SVA, more lordotic global and regional cervical angles (except C0-2 angle), higher T1-slope, larger T1- T12 and T1-Inf kyphotic angles, smaller T12-S1 and Inf-S1 lordotic angles, larger PT, more lordotic SCA, and smaller SS and FAA angles. T1-12/T12-S1 and T1-Inf/Inf-S1 ratios in natural standing, and (Tl-Inf + FAA)/(T1-slope + SCA) ratio in both postures approximate 1. There were significant differences between postures for Tl-l2/Tl2-Sl, Tl-Inf/Inf-Sl and Tl-Inf/SCA ratios. CONCLUSION Whole-body balancing requires understanding of the balance between kyphosis and lordosis, which varies with the posture of patients. Analysis of kypholordotic ratios obtained in this study allude to the importance of performing whole-body imaging in the directed standing posture, and whole-spine or whole-body imaging in the natural standing posture, so as to fully understand spinal and whole body balancing for spinal realignment surgeries.Level of Evidence: Level 3.
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Affiliation(s)
- Hwee Weng Dennis Hey
- University Orthopedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore
| | - Shuxun Lin
- University Orthopedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore
| | - Hui Wen Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yuan Jie Tay
- University Orthopedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore
| | - Gabriel Ka-Po Liu
- University Orthopedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore
| | - Hee-Kit Wong
- University Orthopedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore
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Variation in Sagittal Alignment Parameters in Adult Patients before Spine Surgery: A Serial Imaging Study Using Antero-Posterior and Latero-Lateral Projections. Diagnostics (Basel) 2021; 11:diagnostics11112141. [PMID: 34829487 PMCID: PMC8620822 DOI: 10.3390/diagnostics11112141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/04/2021] [Accepted: 11/16/2021] [Indexed: 11/17/2022] Open
Abstract
Sagittal parameters of the spine are closely related to the evaluation and treatment of spine disease. However, there has been little research on variations in preoperative sagittal spinal alignment. This study was conducted to assess the variation in sagittal spinal alignment on serial antero-posterior and latero-lateral projections (EOS imaging) in adult patients before spine surgery. The sagittal parameters of 66 patients were collected from two serial images. Comparison between the first and second sagittal parameters was evaluated using the Wilcoxon signed-rank test. Subgroup analysis was performed based on the time interval between radiographs, patient's age, and type of surgery. The sagittal vertical axis (SVA) exhibited statistically significant changes (p = 0.023), with the mean SVA increasing statistically (61.7 mm vs. 73.6 mm) and standard deviation increasing (51.5 mm vs. 61.6 mm) in the second image. Subgroup analysis showed significant differences in SVA (p = 0.034) in patients with an interval of >3 months; statistical differences in borderline levels in the SVA (p = 0.049) were observed in patients aged >65 years. Other parameters did not show statistically significant differences, except for SVA. Furthermore, SVA differences were statistically significant with increases in the EOS interval (>3 months) and patient age (>65 years).
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Hey HWD, Tan JH, Ong B, Kumar A, Liu G, Wong HK. Pelvic and sacral morphology and their correlation with pelvic incidence, lumbar lordosis, and lumbar alignment changes between standing and sitting postures. Clin Neurol Neurosurg 2021; 211:107019. [PMID: 34775257 DOI: 10.1016/j.clineuro.2021.107019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 10/19/2022]
Abstract
STUDY DESIGN Retrospective Cross-Sectional Radiographic Study. OBJECTIVE This study aims to describe novel radiographic markers of sacropelvic morphology to further define the static and dynamic relationship between the pelvis and the spine, via the analysis of two postures - standing and sitting. SUMMARY OF BACKGROUND DATA There is increasing evidence underlining the importance of spinopelvic radiographic parameters in the holistic management of sagittal spinal deformity given the close relationship between pelvic morphology and spinal profile. METHODS This is a retrospective radiographic study of patients who presented with the first episode of isolated mechanical, low back pain of fewer than 3 months' duration. All patients underwent whole spine radiographs using EOS technology in both standing and relaxed sitting postures. Six novel distance measurements (H1, H2, H3, V1, V2, DD) to determine pelvic dimensions, and 3 novel angles (A, B, C) to determine sacral morphology were described. RESULTS A total of 64 males (58.2%) and 46 females (41.8%) with a mean age of 42.8 ± 18.6 (range:17-81) years old was studied. Between standing and relaxed sitting postures, differences were observed in all sagittal radiographic parameters. Multivariate analysis showed that standing LL< 500 (p = 0.008), standing V1 > 13 cm(p = 0.040), and angle B> 800(p = 0.002) are predictive of PI< 500, standing TK< 300 (p = 0.003) and PI< 500 (p = 0.006) are predictive of LL< 500, and standing PT< 170(p = 0.034), standing H3 ≥ 4 cm (p = 0.030), standing angle C< 420 (p = 0.003), sitting SS≥ 60 (p = 0.002), and sitting PT < 450 (p = 0.013) are predictive of change in LL below mean difference of 420 between standing and relaxed sitting. CONCLUSIONS Apart from the known correlation between TK, LL and PI, low PI was found to be associated with a tall pelvis and a straight sacrum (angle B). Association between a small coccygeal inclination angle (angle C) and smaller change in LL between standing and relaxed sitting may have clinical relevance.
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Affiliation(s)
- Hwee Weng Dennis Hey
- Department of Orthopaedic Surgery, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Jun-Hao Tan
- Department of Orthopaedic Surgery, National University Hospital, Singapore.
| | - Bernard Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Akshay Kumar
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Gabriel Liu
- Department of Orthopaedic Surgery, National University Hospital, Singapore.
| | - Hee-Kit Wong
- Department of Orthopaedic Surgery, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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Hey HWD, Lim JXY, Tan CS, Liu GKP, Wong HK. Audit and Comparison Between Radiographic Markers of Gaze Direction Using EOS Imaging - An Essential Step to Streamline Existing Methods. Spine (Phila Pa 1976) 2021; 46:E1202-E1210. [PMID: 34474453 DOI: 10.1097/brs.0000000000004213] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study on prospectively implemented EOS protocol. OBJECTIVE This study aims to audit and compare existing radiological definitions of gaze direction-chin brow vertical angle (CBVA), McGregor slope (McGS), slope of line of sight (SLS), orbital-internal occipital protuberance (OIOP) slope angle, and Tangent to the hard palate (THP) in a neutral, healthy, and asymptomatic cohort. SUMMARY OF BACKGROUND DATA The ability to accurately define direction of gaze is the first step when striving for horizontal gaze restoration in any affected individual with rigid sagittal deformity. Yet, the radiological definition of gaze direction remains poorly standardized. METHODS Hundred healthy subjects who could achieve horizontal gaze underwent whole-body standing EOS radiographs taken under a strictly standardized protocol. Radiographic measurements of global spinal sagittal parameters and surrogate measures of horizontal gaze were analyzed and compared. RESULTS The mean age was 45 ± 15.9 years, with a balanced male-to-female-ratio. Their C7 SVA was -7.7 mm ± 24.8 mm, PI was 51.0o ± 11.4o, PI-LL was -0.9o ± 13.0o and T1-slope was 21.2o ± 9.2o. Measured horizontal gaze parameters were as follows: CBVA (1.07o ± 5.48o), McGS (-3.23o ± 5.63o), SLS (0.45o ± 5.34o), OIOP (5.03o ± 4.66o), THP (-0.17o ± 6.27o). CBVA correlated strongly with McGS (r = 0.679, P < 0.001), SLS (r = 0.592, P < 0.001), OIOP (r = 0.697, P < 0.001), and THP (r = -0.504, P < 0.001). OIOP had the lowest variance amongst all parameters and showed less variability compared to CBVA (SD 4.66 Var 21.69 vs. SD 5.48 Var 30.08, P = .012). Multivariate analysis showed that C2-7 angle was the only parameter found to be associated with OIOP values (P = 0.006). CONCLUSION OIOP is the least variable, and most robust radiological method in determining gaze direction. It uses easily recognizable anatomical landmarks and an angular criterion, which makes it advantageous both with x-rays or slot scanners.Level of Evidence: 3.
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Affiliation(s)
| | - Joel Xue Yi Lim
- Department of Orthopedic Surgery, National University Health System, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Gabriel Ka Po Liu
- Department of Orthopedic Surgery, National University Health System, Singapore
| | - Hee Kit Wong
- Department of Orthopedic Surgery, National University of Singapore, Singapore
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Baker JF. Computed tomography study of the relationship between pelvic incidence and bony contribution to lumbar lordosis in children. Clin Anat 2021; 34:934-940. [PMID: 34003513 DOI: 10.1002/ca.23756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/31/2021] [Accepted: 05/06/2021] [Indexed: 12/22/2022]
Abstract
There is little data regarding the relationship in children and how it may change with aging. The aim of this radiographic study was to define the relationship between pelvic incidence (PI) and segmental vertebral body lordosis through childhood. In 150 children, CT scans of the lumbar spine and pelvis were analyzed measuring PI, sacral table angle (STA), sacral kyphosis (SK), and segmental lordosis (SL) individually L1-L5. Children were grouped by age: (1) 0-60 months; (2) 61-120 months; (3) 121-185 months. Mean PI for the entire cohort was 40.4, mean SL for L1-0.6, L2 0.0, L3 1.8, L4, 4.7, and L5 11.4. There were 40 children in Group 1, 63 in Group 2 and 37 in Group 3. SL differed between age groups at all levels except at L2. L1 and L2 became more kyphotic with increasing age; L3, L4, and L5 became more lordotic with increasing age. The correlation between PI and SL at each level became stronger with increasing age. Similarly, the correlation between PI and STA and between PI and SK also became stronger with increasing age. As children mature, the relationship between PI and segmental lordosis at each level of the lumbar spine becomes stronger-the relationship between PI and lordosis trends toward that seen in the adult. Future work should aim to define when the adult PI-LL relationship is realized.
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Affiliation(s)
- Joseph F Baker
- Department of Orthopaedic Surgery, Waikato Hospital, Hamilton, New Zealand.,Department of Surgery, University of Auckland, Auckland, New Zealand
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Risk Factors Predicting C- Versus S-shaped Sagittal Spine Profiles in Natural, Relaxed Sitting: An Important Aspect in Spinal Realignment Surgery. Spine (Phila Pa 1976) 2020; 45:1704-1712. [PMID: 32890306 DOI: 10.1097/brs.0000000000003670] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A cross-sectional study on a randomly selected prospective cohort of patients presenting to a single tertiary spine center. OBJECTIVE The aim of this study was to describe the clinical and radiographic parameters of patients with S- and C-shaped thoracolumbar sagittal spinal profiles, and to identify predictors of these profiles in a natural, relaxed sitting posture. SUMMARY OF BACKGROUND DATA Sagittal realignment in adult spinal deformity surgery has to consider the sitting profile to minimize the risks of junctional failure. Persistence of an S-shaped sagittal profile in the natural, relaxed sitting posture may reflect a lesser need to accommodate for this posture during surgical realignment. METHODS Consecutive patients with low back pain underwent whole body anteroposterior and lateral radiographs in both standing and sitting. Baseline clinical data of patients and radiographic parameters of both standing and sitting sagittal profiles were compared using χ, unpaired t tests, and Wilcoxon rank-sum test. Subsequently, using stepwise multivariate logistic regression analysis, predictors of S-shaped curves were identified while adjusting for confounders. RESULTS Of the 120 patients included, 54.2% had S-shaped curves when sitting. The most common diagnoses were lumbar spondylosis (26.7%) and degenerative spondylolisthesis (26.7%). When comparing between patients with S- and C-shaped spines in the sitting posture, only diagnoses of degenerative spondylolisthesis (odds ratio [OR], 5.44; P = 0.01) and degenerative scoliosis (OR, 2.00; P = 0.039), and pelvic incidence (PI) >52.5° (OR, 5.48; P = 0.008), were predictive of an S-shaped sitting sagittal spinal alignment on multivariate analysis. CONCLUSION Stiffer lumbar curves (eg, patients with degenerative spondylolisthesis and degenerative scoliosis) or those who have a predilection for an S-shaped standing sagittal profile when sitting (eg, high PI) may be more amenable to fusion in accordance with previously studied sagittal realignment targets. In contrast, more flexible curves may benefit from less aggressive lordotic realignment to prevent potential junctional failures. LEVEL OF EVIDENCE 3.
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Ball JR, Konigsberg MW, Plachta S, Fields MW, Matsumoto H, Roye BD, Arora S, Roye DP, Lenke LG, Skaggs DL, Vitale MG. Variability in stable sagittal vertebra (SSV) during full-length biplanar xrays can affect the choice of fusion levels in patients with adolescent idiopathic scoliosis (AIS). Spine Deform 2020; 8:1261-1267. [PMID: 32666471 DOI: 10.1007/s43390-020-00166-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 06/30/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Surgical planning for Adolescent Idiopathic Scoliosis (AIS) relies on the coronal and sagittal plane to determine the lowest instrumented vertebra (LIV). Failure to include the stable sagittal vertebra (SSV) within the construct can increase the incidence of postoperative distal junctional kyphosis (DJK). The purpose of this study is to assess the variability of SSV within patients and to identify positional parameters that may lead to its change. METHODS This is a case-control study of AIS patients with changes in SSV throughout serial radiographs. Radiographic sagittal parameters and hand positioning for the patients with changes in SSV were compared to patients with stable SSV. Additionally, a subgroup analysis was conducted to compare the positional parameters of only the patients with changes in SSV. RESULTS 46 patients with a mean age of 15 ± 1.8 years old at the time of surgery were included in this study. 33/76 (43.4%) image pairs were found to have a change in SSV. Positional parameters associated with the more distally measured SSV were found to have a more negative sagittal vertebral axis (p = 0.001), more positive pelvic shift (p = 0.023), and more negative Global Sagittal Axis (p = 0.001) when compared to the more proximally measured SSV. CONCLUSION Significant variability exists in the determination of SSV in AIS patients undergoing serial radiographs. Positional parameters associated with the proximal and distally measured SSV also have variability which indicates that posture has a significant impact on this measure. Surgeons need to be aware of SSV variability during preoperative planning and must consider multiple parameters for the determination of LIV. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Jacob R Ball
- Department of Pediatric Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center, ATTN: Michael Vitale, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA
| | - Matthew W Konigsberg
- Department of Pediatric Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center, ATTN: Michael Vitale, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA
| | - Stephen Plachta
- Department of Pediatric Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center, ATTN: Michael Vitale, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA
| | - Michael W Fields
- Department of Pediatric Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center, ATTN: Michael Vitale, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA
| | - Hiroko Matsumoto
- Department of Pediatric Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center, ATTN: Michael Vitale, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA
| | - Benjamin D Roye
- Department of Pediatric Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center, ATTN: Michael Vitale, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA
| | - Sushrut Arora
- Department of Pediatric Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center, ATTN: Michael Vitale, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA
| | - David P Roye
- Department of Pediatric Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center, ATTN: Michael Vitale, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA
| | - Lawrence G Lenke
- Department of Pediatric Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center, ATTN: Michael Vitale, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA
| | - David L Skaggs
- Department of Orthopedic Surgery, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Michael G Vitale
- Department of Pediatric Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center, ATTN: Michael Vitale, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA.
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Lee SH, Hyun SJ, Jain A. Cervical Sagittal Alignment: Literature Review and Future Directions. Neurospine 2020; 17:478-496. [PMID: 33022153 PMCID: PMC7538362 DOI: 10.14245/ns.2040392.196] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/13/2020] [Indexed: 12/26/2022] Open
Abstract
Cervical alignment as a concept has come to the forefront for spine deformity research in the last decade. Studies on cervical sagittal alignment started from normative data, and expanded into correlation with global sagittal balance, prognosis of various conditions, outcomes of surgery, definition and classification of cervical deformity, and prediction of targets for ideal cervical reconstruction. Despite the recent robust research efforts, the definition of normal cervical sagittal alignment and cervical spine deformity continues to elude us. Further, many studies continue to view cervical alignment as a continuation of thoracolumbar deformity and do not take into account biomechanical features unique to the cervical spine that may influence cervical alignment, such as the importance of musculature connecting cranium-cervical-thoracic spine and upper extremities. In this article, we aim to summarize the relevant literature on cervical sagittal alignment, discuss key results, and list potential future direction for research using the '5W1H' framework; "WHO" are related?, "WHY" important?, "WHAT" to evaluate and "WHAT" is normal?, "HOW" to evaluate?, "WHEN" to apply sagittal balance?, and "WHERE" to go in the future?
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Affiliation(s)
- Sang Hun Lee
- Department of Orthopaedic Surgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Seung-Jae Hyun
- Department of Neurological Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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Comparison of whole body sagittal alignment during directed vs natural, relaxed standing postures in young, healthy adults. Spine J 2019; 19:1832-1839. [PMID: 31233893 DOI: 10.1016/j.spinee.2019.06.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 06/14/2019] [Accepted: 06/14/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Imaging for adult spinal deformity is conventionally performed in a directed manner to assess the most upright standing posture one can assume. However, this method does not reflect an individual's natural, relaxed posture, which is the posture a patient likely reverts to postoperatively, and also the posture likely to explain spinal pathologies. PURPOSE To identify radiographic differences between directed and natural, relaxed standing postures in young healthy subjects. STUDY DESIGN A randomized, prospective, radiographic study. PATIENT SAMPLE Sixty healthy 21-year-old subjects (48 male, 12 female). OUTCOME MEASURES Radiographic parameters including sagittal vertical axis (SVA), C2 SVA, C2-7 SVA global cervical angle, T1-slope, global thoracic angle (GTA), thoracolumbar angle (TLA), global lumbar angle (GLA), sacral slope, pelvic tilt (PT), pelvic incidence, femoral alignment angle (FAA), and knee alignment angle (KAA). METHODS The EOS whole body radiographs of patients in directed and natural, relaxed standing postures were obtained, with subsequent comparison of radiographic parameters. Differences in Roussouly curve types, sagittal curve apices, and end vertebrae were also evaluated. Univariate analyses using Wilcoxon sign-rank, paired t tests, and paired chi-square tests were performed. RESULTS Compared with directed standing, natural, relaxed standing results in a more kyphotic spinal profile marked by a significantly less lordotic GLA, larger GTA, TLA, and T1-slope. The PT+FAA demonstrated true hip movement during sagittal balancing. Lower thoracic and lumbar apices, lower thoracolumbar end vertebrae, and lower Roussouly curve types were observed during natural, relaxed standing. CONCLUSIONS Our study found significant differences in sagittal radiographic parameters between directed standing and the natural, relaxed standing posture, with the latter demonstrating a more kyphotic spinal profile in terms of magnitude and span, as well as complementary changes in cervical and spinopelvic alignment. The natural, relaxed standing posture, a marker for energy conservation principles in standing, may infer value in less aggressive lordotic restoration, as well as concentration of lordosis in the lower lumbar spine.
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Lumbosacral loadbearing, sagittal shift in the line of gravity and joint surface areas. Anat Sci Int 2018; 93:566-568. [DOI: 10.1007/s12565-018-0439-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 04/04/2018] [Indexed: 11/27/2022]
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