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Dos Santos Delgado A, Souza Morais B, Luiz Aparecido Defino H, Neto Montagnoli A. Strategies for Minimizing the Effects of Observer Variability on Sagittal Parameter Measurements of the Spine. Clin Spine Surg 2024:01933606-990000000-00323. [PMID: 38842185 DOI: 10.1097/bsd.0000000000001642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 04/29/2024] [Indexed: 06/07/2024]
Abstract
STUDY DESIGN Exploratory-descriptive study. OBJECTIVE Evaluate the influence of observer variability on the measurements of both thoracic kyphosis (TK) and lumbar lordosis (LL) obtained with anatomic and functional spinal segmentation methods. BACKGROUND Parametric analysis for spinal surgery planning typically relies on anatomic parameters. However, incorporating functional parameters that consider the vertebrae orientation is important to minimizing surgical calculation errors. METHODS The authors developed parametric analysis software that integrates traditional and functional methodologies. The proposed method included functional thoracic kyphosis and functional lumbar lordosis calculated from the lines normal to the inflection points of the spine model. Using a synthetic lateral X-ray, the observer variability was computer-simulated generating 20 landmark sets that replicate the annotations of 20 observers. The analysis also included 10 clinical X-rays, annotated twice by 3 judges with a minimum 1-week interval. The spinal curvature angles were derived using the anatomic and functional methods. Statistical analysis were performed for comparison. RESULTS For the synthetic X-ray, the proposed method presented significantly less variability: TK (<±2.5 degrees, P=0.00023) and LL (<±5 degrees, P=0.00012). For the clinical X-rays, the interobserver reliability analysis yielded higher intraclass correlation coefficients (ICC) for functional TK (ICC>0.97) and functional LL (ICC>0.87) than for TK (ICC<0.91) and LL (ICC<0.89). Statistically significant differences were observed for both TK (P=0.001) and LL (P=0.030). Under the traditional method, observer variability led to measurement differences surpassing ±19 degrees, whereas differences with the proposed method were within ±10 degrees for both parameters. CONCLUSION The vertebral endplate is not the most suitable place to measure spinal sagittal curvatures. Small changes in landmark position significantly alter the measured Cobb angle. The proposed method offers a substantial advantage regarding the influence of observer variability, in addition to the more individualized analysis.
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Affiliation(s)
| | - Bruna Souza Morais
- Interunit Graduate Program in Bioengineering, Universidade de São Paulo (USP), São Carlos-SP
| | | | - Arlindo Neto Montagnoli
- Department Electrical Engineering, Universidade Federal de São Carlos (UFSCar), São Carlos-SP, Brasil
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Harrison DE, Haas JW, Moustafa IM, Betz JW, Oakley PA. Can the Mismatch of Measured Pelvic Morphology vs. Lumbar Lordosis Predict Chronic Low Back Pain Patients? J Clin Med 2024; 13:2178. [PMID: 38673450 PMCID: PMC11050312 DOI: 10.3390/jcm13082178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 04/01/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Measures of lumbar lordosis (LL) and elliptical modeling variables have been shown to discriminate between normal and chronic low back pain (CLBP) patients. Pelvic morphology influences an individual's sagittal lumbar alignment. Our purpose is to investigate the sensitivity and specificity of lumbar sagittal radiographic alignment and modeling variables to identify if these can discriminate between normal controls and CLBP patients. Methods: We conducted a computer analysis of digitized vertebral body corners on lateral lumbar radiographs of normal controls and CLBP patients. Fifty normal controls were attained from a required pre-employment physical examination (29 men; 21 women; mean age of 27.7 ± 8.5 years), with no history of low back pain, a normal spinal examination, no pathologies, anomalies, or instability. Additionally, 50 CLBP patients (29 men; 29.5 ± 8 years of age) were randomly chosen and matched to the characteristics of the controls. The inclusion criteria required no abnormalities on lumbar spine radiographs. The parameters included the following: ARA L1-L5 lordosis, ARA T12-S1 lordosis, Cobb T12-S1, b/a elliptical modelling ratio, sacral base angle (SBA), and S1 posterior tangent to vertical (PTS1). Two measures of pelvic morphology were determined for each person-the angle of pelvic incidence (API) and posterior tangent pelvic incidence angle (PTPIA)-and the relationships between API - ARA T12-S1, API - Cobb T12-S1, and API - ARA L1-5 was determined. Descriptive statistics and correlations among the primary variables were determined. The receiver operating characteristic curves (ROC curves) for primary variables were analyzed. Results: The mean values of LL were statistically different between the normal and CLBP groups (p < 0.001), indicating a hypo-lordotic lumbar spine for the CLBP group. The mean b/a ratio was lower in the chronic pain group (p = 0.0066). The pelvic morphology variables were similar between the groups (p > 0.05). API had a stronger correlation to the SBA and Cobb T12-S1 than PTPIA did, while PTPIA had a stronger correlation to the S1 tangent and ARA T12-S1 than API did. While CLBP patients had a stronger correlation of ARA T12-S1 and Cobb T12-S1 relative to the pelvic morphology, they also had a reduced correlation of ARA L1-L5 lordosis relative to their SBA and pelvic morphology measures. API - T12-S1, API - L1-L5, and API - Cobb T12-S1 were statistically different between the groups, p < 0.001. Using ROC curve analyses, it was identified that ARA L1-L5 lordosis of 36° and ARA T12-S1 of 68° have a good sensitivity and specificity to discriminate between normal and CLBP patients. ROC curve analyses identified that lordosis ARAT12-S1 < 68° (AUC = 0.83), lordosis ARAL1-L5 < 36° (AUC = 0.78), API - ARA T12-S1 < -18° (AUC = 0.75), API - ARAL1-L5 > 35° (AUC = 0.71), and API - Cobb T12-S1 < -5° (AUC = 0.69) had moderate to good discrimination between groups (AUC = 0.83, 0.78, 0.75, and 0.72). Conclusions: Pelvic morphology is similar between normal and CLBP patients. CLBP patients have an abnormal 'fit' of their API - ARAT12-S1 and L1-L5 lumbar lordosis relative to their pelvic morphology and sacral tilt shown as a hypolordosis.
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Affiliation(s)
| | - Jason W. Haas
- Chiropractic Biophysics NonProfit, Inc., Eagle, ID 83616, USA
| | - Ibrahim M. Moustafa
- Department of Physiotherapy, College of Health Sciences, University of Sharjah, Sharjah 27272, United Arab Emirates;
- Neuromusculoskeletal Rehabilitation Research Group, RIMHS–Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah 27272, United Arab Emirates
| | | | - Paul A. Oakley
- Kinesiology and Health Science, York University, Toronto, ON M3J 1P3, Canada;
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Diebo BG, Balmaceno-Criss M, Lafage R, McDonald CL, Alsoof D, Halayqeh S, DiSilvestro KJ, Kuris EO, Lafage V, Daniels AH. Sagittal Alignment in the Degenerative Lumbar Spine: Surgical Planning. J Bone Joint Surg Am 2024; 106:445-457. [PMID: 38271548 PMCID: PMC10906213 DOI: 10.2106/jbjs.23.00672] [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: 01/27/2024]
Abstract
➤ Sagittal alignment of the spine has gained attention in the field of spinal deformity surgery for decades. However, emerging data support the importance of restoring segmental lumbar lordosis and lumbar spinal shape according to the pelvic morphology when surgically addressing degenerative lumbar pathologies such as degenerative disc disease and spondylolisthesis.➤ The distribution of caudal lordosis (L4-S1) and cranial lordosis (L1-L4) as a percentage of global lordosis varies by pelvic incidence (PI), with cephalad lordosis increasing its contribution to total lordosis as PI increases.➤ Spinal fusion may lead to iatrogenic deformity if performed without attention to lordosis magnitude and location in the lumbar spine.➤ A solid foundation of knowledge with regard to optimal spinal sagittal alignment is beneficial when performing lumbar spinal surgery, and thoughtful planning and execution of lumbar fusions with a focus on alignment may improve patient outcomes.
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Affiliation(s)
- Bassel G. Diebo
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Mariah Balmaceno-Criss
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Christopher L. McDonald
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Daniel Alsoof
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Sereen Halayqeh
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Kevin J. DiSilvestro
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Eren O. Kuris
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Alan H. Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
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Hohenhaus M, Volz F, Merz Y, Watzlawick R, Scholz C, Hubbe U, Klingler JH. The challenge of measuring spinopelvic parameters: inter-rater reliability before and after minimally invasive lumbar spondylodesis. BMC Musculoskelet Disord 2022; 23:104. [PMID: 35101020 PMCID: PMC8802499 DOI: 10.1186/s12891-022-05055-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The common manual measurement technique of spinal sagittal alignment on X-rays is susceptible to rater-dependent variability, which has not been adequately considered in previous publications. This study investigates the effect of those variations in the characterization of patients receiving lumbar spondylodesis. METHODS General alignment parameters on pre- and postoperative X-rays were evaluated by four raters in 43 prospectively sampled patients undergoing monolevel spondylodesis. The Intra-class Correlation Coefficient (ICC) for each rater pair and all raters together was calculated for inter-rater reliability. For the operation-induced change of the sagittal alignment in every patient the Wilcoxon test was applied to compare for each rater separately. RESULTS The ICCs were "good" (>0.75) to "excellent" (>0.9) for all raters together and for 45 of the 48 single rater pairs (93.75%). All revealed a significant increase of the addressed segmental lordosis and disc height and no significant change for spinopelvic parameters and sagittal vertical axis from pre- to postoperative. The lumbar lordosis showed a significant increase through the operation of +2.5° (p = 0.014) and +3.7° (p = 0.015) in two raters and no difference for the other ones (+2.1°, p = 0.171; -2.2°, p = 0.522). CONCLUSIONS The pre- to postoperative change of lumbar lordosis revealed different significance levels for different raters, although the ICCs were formally good. Accordingly, the evaluation by only one rater would lead to different conclusions. Due to this susceptibility of alignment measurements to rater-dependent variability, the exact evaluation process should be described in every publication and the consistency of significant results be validated through multiple raters. TRIALS REGISTRATION The trial was approved by the local ethics committee and listed at the national clinical trials register ( DRKS00004514 , date of registration: 08/11/2012).
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Affiliation(s)
- Marc Hohenhaus
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Florian Volz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Yorn Merz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Ralf Watzlawick
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Christoph Scholz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Ulrich Hubbe
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Jan-Helge Klingler
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
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RODRIGUES FERNANDOMANSANO, TANEJA ATULKUMAR, NARAHASHI ERICA, SILVA FLAVIODUARTE, FERNANDES ARTURROCHACORRÊA, FALOTICO GUILHERMEG, YAMADA ANDRÉFUKUNISHI. PELVIC INCIDENCE AND OSTEITIS PUBIS IN PROFESSIONAL SOCCER PLAYERS. ACTA ORTOPEDICA BRASILEIRA 2022; 30:e244380. [PMID: 35431631 PMCID: PMC8979358 DOI: 10.1590/1413-785220223001e244380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/10/2021] [Indexed: 05/31/2023]
Abstract
Introduction. Osteitis pubis is a common inflammatory disease of the pubic symphysis, defined as a chronic pain syndrome caused by repetitive microtrauma. Since adaptative changes are necessary in the pelvis to adjust the equilibrium of the myotendinous structures, the aim of this study was to evaluate the correlation between pelvic incidence and osteitis pubis among professional soccer players. Materials and Methods. An observational, cross-sectional study was performed with professional soccer players from five teams during pre-season. Athletes with previous congenital pelvic abnormalities or a history of surgery were excluded. Radiographs of the pelvis were analyzed by two radiologists and assessed for findings consistent with osteitis pubis, and the following parameters were measured: pelvic incidence (PI), sacral inclination (SI), and pelvic version (PV). Results. A total of 107 subjects were included in the study, with a mean age of 25.6 ± 3.1 years. Findings compatible with osteitis pubis were present in 74.8% of the subjects (80/107). There was no statistical correlation between osteitis pubis and PI (52.3°±12.7° vs. 48.4°±10.8°; p=0.156), SI (43.1°±9.8° vs. 39.9°±10.1°; p=0.146), or PV (9.2°± 6.3° vs 8.6°± 7.5°; p=0.649). Agreement between readers was excellent (p<0.0001). Conclusion. There was no significant correlation between pelvic parameters and radiographic diagnosis of osteitis pubis. Leve of Evidence II; Diagnostic study.
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Affiliation(s)
| | - ATUL KUMAR TANEJA
- Hospital do Coração, Brazil; Hospital Israelita Albert Einstein, Brazil
| | | | | | | | | | - ANDRÉ FUKUNISHI YAMADA
- Universidade Federal de São Paulo, Brazil; Hospital do Coração, Brazil; Diagnósticos da América SA, Brazil
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Im SK, Lee KY, Lim HS, Suh DU, Lee JH. Optimized Surgical Strategy for Adult Spinal Deformity: Quantitative Lordosis Correction versus Lordosis Morphology. J Clin Med 2021; 10:jcm10091867. [PMID: 33925824 PMCID: PMC8123441 DOI: 10.3390/jcm10091867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/20/2021] [Accepted: 04/22/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In surgical correction of adult spinal deformity (ASD), pelvic incidence (PI)-lumbar lordosis (LL) plays a key role to restore normal sagittal alignment. Recently, it has been found that postoperative lordosis morphology act as an important factor in preventing mechanical complications. However, there have been no studies on the effect of postoperative lordosis morphology on the restoration of sagittal alignment. The primary objective of this study was to evaluate the effect of postoperative lordosis morphology on achievement of optimal sagittal alignment. The secondary objective was to find out which radiographic or morphologic parameter affects sagittal alignment in surgical correction of ASD. METHODS 228 consecutive patients with lumbar degenerative kyphosis who underwent deformity correction and long-segment fixation from T10 to S1 with sacropelvic fixation and follow-up over 2 years were enrolled. Patients were divided according to whether optimal alignment was achieved (balanced group) or not (non-balanced group) at last follow-up. We analyzed the differences of postoperative radiographic parameters and morphologic parameters between two groups. Correlation analysis and stepwise multiple linear regression analysis was performed to predict the effect of PI-LL and morphologic parameters on the sagittal vertical axis (SVA). RESULTS Of 228 patients, 195 (85.5%) achieved optimal alignment at last follow-up. Two groups significantly differed in postoperative and last follow-up LL (p < 0.001 and p = 0.028, respectively) and postoperative and last follow-up PI-LL (p < 0.001 and p = 0.001, respectively). Morphologic parameters did not significantly differ between the two groups except lower lordosis arc angle (=postoperative sacral slope). In correlation analysis and stepwise multiple linear regression analysis, postoperative PI-LL was the only parameter which had significant association with last follow-up SVA (R2 = 0.134, p < 0.001). Morphologic parameters did not have any association with last follow-up SVA. CONCLUSIONS When planning spine reconstruction surgery, although considering postoperative lordosis morphology is necessary, it is still very important considering proportional lordosis correction based on individual spinopelvic alignment (PI-LL) to achieve optimal sagittal alignment.
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Revisiting thoracic kyphosis: a normative description of the thoracic sagittal curve in an asymptomatic population. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 30:1184-1189. [PMID: 33222002 DOI: 10.1007/s00586-020-06670-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 11/15/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Thoracic kyphosis (TK) remained in the shadow of lumbar lordosis. Based on Berthonnaud and Roussouly segmentation, TK is divided into two arches: upper TK (UTK) and lower TK (LTK). The purpose of this study is to propose a normative description of the TK arches in an asymptomatic adults' population and their correlation with spinal and pelvic parameters. METHODS This is an observational study performed on asymptomatic healthy Caucasians volunteers aged between 18 and 45 years. Each patient had a standardized standing biplanar full spine X-rays. Using KEOPS®, sacropelvic parameters and global spinal parameters (LL, TK) as well as the inflexion point location were measured. The upper lumbar lordosis angle (ULL) as well as LTK and UTK was calculated. Patients were classified according to Roussouly morphotypes of normal spine. RESULTS A total of 373 adults (F/M = 1.4/1) were enrolled with mean age of 27 years. Mean UTK averaged 25.8°, while mean LTK averaged 19.8° (p < 0.001). UTK angle values were statistically the same in the five different Roussouly spinal shapes (p > 0.05), while LTK values were variable among different Roussouly spine subtypes (p < 0.05). Finally, TK showed the highest correlation with the LL mainly with the ULL (Pearson = 0.66). CONCLUSION In asymptomatic young adults, thoracic kyphosis is composed by two unequal arches, a stable UTK and a variable LTK, with an apex around T8 and T9 vertebra, depending on the spinal morphotype according to Roussouly classification. This should be taken into consideration when analyzing spine sagittal compensation and preparing corrections to minimize risk of mechanical complications.
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OKAN S, BEYHAN M. Lomber subkutan yağ doku kalınlığının spinopelvik parametrelerle ilişkisi. CUKUROVA MEDICAL JOURNAL 2020. [DOI: 10.17826/cumj.736745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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A deep learning tool for fully automated measurements of sagittal spinopelvic balance from X-ray images: performance evaluation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:2295-2305. [DOI: 10.1007/s00586-020-06406-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 03/10/2020] [Accepted: 03/30/2020] [Indexed: 12/20/2022]
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Mechanical complications in adult spinal deformity and the effect of restoring the spinal shapes according to the Roussouly classification: a multicentric study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 29:904-913. [PMID: 31875922 DOI: 10.1007/s00586-019-06253-1] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/28/2019] [Accepted: 11/19/2019] [Indexed: 01/30/2023]
Abstract
PURPOSE To evaluate the incidence of mechanical complications in patients with adult spine deformity (ASD) treated by restoring the normal shape according to the Roussouly classification. METHODS This is a retrospective multicentric study with a minimum follow-up of 2 years. Patients operated on with fusion for ASD (minimum performed fusion: L2 to sacrum) were included. Patients with a history of previous spinal fusion of more than three levels were excluded. Spinal and pelvic parameters were measured on the preoperative and the immediate postoperative follow-up. All mechanical complications were recorded. RESULTS A total of 290 patients met the criteria of inclusion with a minimum follow-up of 2 years. Mechanical complications occurred in 30.4% of the cohort. The most common complication was PJK with an incidence of 18% while nonunion or instrumentation failure (rod breakage, implant failure) occurred in 12.4%. 66% of the patients were restored to the normal shape according to the Roussouly classification based on their PI and had a mechanical complication rate of 22.5%, whereas the remaining 34% of patients had a complication rate of 46.8% (p < 0.001). The relative risk for developing a mechanical complication if the algorithm was not met was 3 (CI 1.5-4.3; p < 0.001) CONCLUSION: In the recent literature, there are no clear guidelines for ASD correction. Restoring the sagittal spinal contour to the normal shapes of Roussouly according to the PI could serve as a guideline for ASD treatment. Ignoring this algorithm has a threefold risk of increased mechanical complications. We recommend this algorithm for treatment of ASD. LEVEL OF EVIDENCE IV cross-sectional observational study. These slides can be retrieved under Electronic Supplementary Material.
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Bari TJ, Hallager DW, Tøndevold N, Karbo T, Hansen LV, Dahl B, Gehrchen M. Spinopelvic Parameters Depending on the Angulation of the Sacral End Plate Are Less Reproducible Than Other Spinopelvic Parameters in Adult Spinal Deformity Patients. Spine Deform 2019; 7:771-778. [PMID: 31495478 DOI: 10.1016/j.jspd.2018.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/27/2018] [Accepted: 12/03/2018] [Indexed: 11/18/2022]
Abstract
STUDY DESIGN Reproducibility study. OBJECTIVES To report the agreement and reliability for commonly used sagittal plane measurements. SUMMARY OF BACKGROUND DATA Spinopelvic parameters and sagittal vertical axis (SVA) are commonly used parameters for preoperative planning and postoperative evaluation of patients with adult spinal deformity (ASD). Previous reproducibility studies have focused on describing the reliability using intraclass correlation coefficients (ICCs), thus quantifying the methods' ability to distinguish between individuals. To our knowledge, no previous study in patients with ASD has reported the measurement error in terms of limits of agreement. The current study aimed to report the agreement and reliability for measurements of pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and SVA in ASD patients. METHODS In a consecutive, one-center cohort of 64 patients referred for ASD evaluation, a blinded test-retest study was performed. Reliability was assessed using ICCs, whereas 95% limits of agreement (LOAs) were used to quantify agreement. RESULTS We found "excellent" (ICC > 0.9) results in all analyses of reliability except for interrater PI, which was classified as "good" (ICC = 0.89). However, considerable interrater measurement error was observed for parameters depending on the angulation of the sacral end plate (95% LOA of ±11° and ±14° for SS and PI, respectively) compared with ±5° for PT and ±7 mm for SVA, which depends on the location of the sacral end plate. Intrarater agreement was only slightly better. CONCLUSION These are to our knowledge the first estimates of measurement error for sagittal spinopelvic parameters in ASD patients. Despite near excellent ICCs, we found considerable measurement error for parameters depending on the angulation rather than the location of the sacral end plate. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Tanvir Johanning Bari
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark.
| | - Dennis Winge Hallager
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Niklas Tøndevold
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ture Karbo
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Lars Valentin Hansen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Benny Dahl
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital and Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
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Inter/Intraobserver Reliability of T1 Pelvic Angle (TPA), a Novel Radiographic Measure for Global Sagittal Deformity. Spine (Phila Pa 1976) 2018; 43:E1290-E1296. [PMID: 29659441 DOI: 10.1097/brs.0000000000002689] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Reliability analysis. OBJECTIVE To assess intra- and interobserver agreement of the T1 pelvic angle (T1PA), a novel radiographic measure of spinal sagittal alignment. Orthopedic surgeons of various levels of experience measured the T1PA in a series of healthy adult volunteers. The relationship of the TIPA to pelvic position was also assessed. SUMMARY OF BACKGROUND DATA Recent literature suggests that the T1PA is a more reliable measure of global sagittal alignment than traditional measurements (i.e., sagittal vertical axis). Previous research focuses on postoperative patients with known spinal deformity. No published research exists evaluating the use of T1PA on healthy subjects without spinal deformity. The purpose of this study is: (1) to assess the reliability of measurements of the T1PA, (2) to examine its relationship to pelvic position. METHODS Seven evaluators of varying orthopedic experience measured the T1PA in 50 healthy adult volunteers. Subjects were radiographed in each of three pelvic positions: resting, maximal anterior pelvic rotation, and maximal posterior pelvic rotation. After a washout period, the measurement was repeated. Using intraclass correlation coefficients, the intra- and inter-rater agreement for the T1PA was measured. The collected data was also used to determine the accuracy of this measurement and its relationship to pelvic position. RESULTS A very high level of agreement was found in measurements of the T1PA (intraclass correlation coefficients r = 0.98). At each pelvic position, all examiners had excellent intrarater reliability, > 0.85. The inter-rater reliability, compared with a gold standard, consistently measured the T1PA within ± 2°. The data also shows that the T1PA changes with pelvic rotation. CONCLUSION T1PA is a reproducible and reliable measure of global sagittal alignment regardless of the level of training. The T1PA varies based on pelvic rotation; this variation must be taken into account when assigning an absolute target for correction. LEVEL OF EVIDENCE 4.
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Sebaaly A, El Rachkidi R, Grobost P, Burnier M, Labelle H, Roussouly P. L5 incidence: an important parameter for spinopelvic balance evaluation in high-grade spondylolisthesis. Spine J 2018; 18:1417-1423. [PMID: 29360579 DOI: 10.1016/j.spinee.2018.01.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/28/2017] [Accepted: 01/11/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND In high-grade spondylolisthesis (HGSPL), the pelvic incidence (PI) is not a reliable measurement because of doming of the sacrum. Measurement of L5 incidence (L5I) was described as a tool to measure pelvic morphology in HGSPL and for surgical follow-up. OBJECTIVE We aimed to evaluate L5I in HGSPL and its relationship to other spinopelvic parameters. STUDY DESIGN A retrospective study of a cohort of 184 patients with HGSPL was carried out. METHODS Whole spine radiographs were analyzed for PI, pelvic tilt (PT), sacral slope, lumbar lordosis (LL), L5I, L5 tilt (L5T), L5 slope, lumbosacral kyphosis, and slip percentage. Statistical analysis and correlation were made (Pearson correlation test; p<.05). In accordance to Cohen, statically significant correlation were considered strong if R>0.5, moderate if 0.3<R<0.5, and small if R<0.3. RESULTS A total of 184 cases were analyzed, with a female-to-male ratio of 2.35 and a mean age of 20.1 years. Sacral doming was present in 73% of the cases. Mean L5I incidence was 65.2° and strongly correlated to other sagittal parameters, especially PT (R=0.7), LL (R=0.7), L5T (R=0.77), and L5 slope (R=0.83). There was less but still strong correlation to Dubousset lumbosacral kyphosis (Dub-LSK) angle (R=-0.63) and percentage of slippage (R=0.56). L5 tilt showed nearly perfect correlation to PT (R=0.95). Forty-four percent of the cases were balanced HGSPL, whereas 56% of the cases were unbalanced HGSPL. L5 incidence was found to be a good predictor of local imbalance with a cutoff of L5I=61. CONCLUSION This paper describes L5I, which is a positional parameter in HGSPL. L5 incidence is a simple and reliable measure in the preoperative setting in HGSPL. Its correlation with spinal sagittal parameters (especially PT and LL) is strong and was found to be better than Dub-LSK. There is also a good correlation between L5I and HGSPL pelvic parameters (slip percentage and lumbosacral kyphosis). We recommend its use for evaluation of surgical correction and recommend the value of 60° as cutoff value to define spinopelvic balance in HGSPL.
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Affiliation(s)
- Amer Sebaaly
- Department of Orthopedic Surgery, Clinique médico-chirurgicale des Massues, 92 Rue Edmond Locard, 69005 Lyon, France; Faculty of Medicine, Saint Joseph University, Damascus Rd, 1107 2180, Beirut, Lebanon.
| | - Rami El Rachkidi
- Faculty of Medicine, Saint Joseph University, Damascus Rd, 1107 2180, Beirut, Lebanon; Department of Orthopedic Surgery, Hotel Dieu de France, Alfred Naccache St, 166830, Achrafieh, Beirut, Lebanon
| | - Pierre Grobost
- Department of Orthopedic Surgery, Clinique médico-chirurgicale des Massues, 92 Rue Edmond Locard, 69005 Lyon, France
| | - Marion Burnier
- Department of Orthopedic Surgery, Clinique médico-chirurgicale des Massues, 92 Rue Edmond Locard, 69005 Lyon, France
| | - Hubert Labelle
- Sainte-Justine University Hospital Center, 3175 Chemin de la Côte-Sainte-Catherine, Montréal, QC H3T 1C5, Canada
| | - Pierre Roussouly
- Department of Orthopedic Surgery, Clinique médico-chirurgicale des Massues, 92 Rue Edmond Locard, 69005 Lyon, France
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Wei X, Gengwu L, Chao C, Yifan L, Shang S, Ruixi H, Yunhan J, Xiaodong Z, Zhikun L. Correlations between the sagittal plane parameters of the spine and pelvis and lumbar disc degeneration. J Orthop Surg Res 2018; 13:137. [PMID: 29866146 PMCID: PMC5987659 DOI: 10.1186/s13018-018-0838-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 05/18/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Studies have shown that lumbar disc herniation, degenerative lumbar instability, and other degenerative lumbar spinal diseases are often secondary to disc degeneration. By studying the intervertebral disc, researchers have clarified the pathological changes involved in intervertebral disc degeneration but have ignored the roles of biomechanical factors in the development of disc degeneration. This study aims to investigate the relationships among the location, scope, and extent of lumbar disc degeneration and sagittal spinal-pelvic parameters. METHODS A retrospective analysis was performed on the clinical data of 284 patients with lumbar degenerative disc diseases (lumbar disc herniation and degenerative lumbar instability) from January 2013 to December 2016. Statistics were calculated for the following: (1.) patients' general information: name, sex, age, height, and weight. (2.) Measurements of sagittal parameters from total spinal radiographs: thoracic kyphosis (TK), Lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), sagittal vertical axis (SVA), T1 tilt angle (TA), and T1 pelvic angle (TPA). (3.) Location, scope, extent, and overall degree of lumbar disc degeneration. Parameters were analyzed in groups by sex, PI, and SVA, and a correlation analysis was performed for the location, scope, extent, and overall degree of lumbar intervertebral disc degeneration with 8 spinal-pelvic sagittal parameters. RESULTS The mean ages of the male and female patient groups were 59.00 and 53.28 years old, respectively (P < 0.05). The PT, location, scope, and overall degree of degradation were significantly different between the sexes (P < 0.05). Linear correlation analysis results showed that the overall degree and extent of degradation (r = 0.788, P < 0.01), LL and SS (r = 0.737, P < 0.01), PI and PT (r = 0.607, P < 0.01), and TPA and PT (r = 0.899, P < 0.01) were strongly correlated. The location values were 4.08 ± 0.72 in patients with PI≤50° and 3.62 ± 0.94 in patients with PI> 50° (P = 0.018). Different SVASVA groups differed in their overall degree of degeneration (P = 0.002). CONCLUSIONS The location of lumbar intervertebral disc degeneration is affected by spinal-pelvic sagittal morphology. Populations with small PI values tend to exhibit degeneration at the L4/5 and L5/S1 discs, and populations with large PI values tend to exhibit degeneration at the L3/4 and L4/5 discs. The SVA value and the overall degree of lumbar disc degeneration are positively correlated.
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Affiliation(s)
- Xu Wei
- Department of Orthopedics, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, 1111 XianXia Road, Shanghai, 200336, People's Republic of China
| | - Li Gengwu
- Department of Orthopedics, Panzhihua Central Hospital, 34 YiKang Road, Panzhihua, 617017, Sichuan Province, People's Republic of China
| | - Chen Chao
- Department of Orthopedics, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, 1111 XianXia Road, Shanghai, 200336, People's Republic of China
| | - Li Yifan
- Department of Orthopedics, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, 1111 XianXia Road, Shanghai, 200336, People's Republic of China
| | - Sang Shang
- Department of Orthopedics, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, 1111 XianXia Road, Shanghai, 200336, People's Republic of China
| | - Hu Ruixi
- Department of Orthopedics, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, 1111 XianXia Road, Shanghai, 200336, People's Republic of China
| | - Ji Yunhan
- Department of Orthopedics, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, 1111 XianXia Road, Shanghai, 200336, People's Republic of China
| | - Zhu Xiaodong
- Department of Orthopedics, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, 1111 XianXia Road, Shanghai, 200336, People's Republic of China.
| | - Li Zhikun
- Department of Orthopedics, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, 1111 XianXia Road, Shanghai, 200336, People's Republic of China.
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Abstract
STUDY DESIGN This is a observational study. OBJECTIVE To evaluate the reliability of measuring sagittal spinopelvic alignment after hip arthroplasty. SUMMARY OF BACKGROUND DATA Pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), and lumbar lordosis (LL) are widely used in planning the treatment of people with spinal and hip disorders. Previously, these measures have proved reliable when hip heads are intact. Thus far, it is not known whether they are also reliable after total hip replacement. MATERIALS AND METHODS Two observers assessed PI, SS, PT, and LL in the radiographs of 97 patients who had undergone total hip replacement. Test-retest (intraobserver) and interobserver reliability were estimated. RESULTS The intraclass correlation coefficient ranged from 0.92 to 0.97 and 0.85 to 0.94 for the intraobserver and interobserver settings, respectively, indicating an almost perfect correlation between observers or observations. The absolute intrarater measurement errors were 1.41 [95% confidence interval (CI), 0.98-2.03) for PI, 1.16 (95% CI, 0.78-1.74) for SS, 0.49 (95% CI, 0.31-0.76) for PT, and 1.75 (95% CI, 1.22-2.51) degrees for LL. The respective interrater figures were 2.82 (95% CI, 2.04-3.9), 2.44 (95% CI, 1.78-3.35), 0.73 (95% CI, 0.48-1.13), and 2.28 (95% CI, 1.55-3.34) degrees. CONCLUSIONS It seems that total hip arthroplasty does not affect the reliability of spinopelvic sagittal alignment measurements. LEVEL OF EVIDENCE Level II.
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Laouissat F, Sebaaly A, Gehrchen M, Roussouly P. Classification of normal sagittal spine alignment: refounding the Roussouly classification. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:2002-2011. [DOI: 10.1007/s00586-017-5111-x] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 03/14/2017] [Accepted: 04/23/2017] [Indexed: 11/30/2022]
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Wong AYL, Karppinen J, Samartzis D. Low back pain in older adults: risk factors, management options and future directions. SCOLIOSIS AND SPINAL DISORDERS 2017; 12:14. [PMID: 28435906 PMCID: PMC5395891 DOI: 10.1186/s13013-017-0121-3] [Citation(s) in RCA: 197] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 04/04/2017] [Indexed: 12/12/2022]
Abstract
Low back pain (LBP) is one of the major disabling health conditions among older adults aged 60 years or older. While most causes of LBP among older adults are non-specific and self-limiting, seniors are prone to develop certain LBP pathologies and/or chronic LBP given their age-related physical and psychosocial changes. Unfortunately, no review has previously summarized/discussed various factors that may affect the effective LBP management among older adults. Accordingly, the objectives of the current narrative review were to comprehensively summarize common causes and risk factors (modifiable and non-modifiable) of developing severe/chronic LBP in older adults, to highlight specific issues in assessing and treating seniors with LBP, and to discuss future research directions. Existing evidence suggests that prevalence rates of severe and chronic LBP increase with older age. As compared to working-age adults, older adults are more likely to develop certain LBP pathologies (e.g., osteoporotic vertebral fractures, tumors, spinal infection, and lumbar spinal stenosis). Importantly, various age-related physical, psychological, and mental changes (e.g., spinal degeneration, comorbidities, physical inactivity, age-related changes in central pain processing, and dementia), as well as multiple risk factors (e.g., genetic, gender, and ethnicity), may affect the prognosis and management of LBP in older adults. Collectively, by understanding the impacts of various factors on the assessment and treatment of older adults with LBP, both clinicians and researchers can work toward the direction of more cost-effective and personalized LBP management for older people.
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Affiliation(s)
- Arnold YL Wong
- Department of Rehabilitation Sciences, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong, SAR China
| | - Jaro Karppinen
- Medical Research Center Oulu, Department of Physical and Rehabilitation Medicine, University of Oulu and Oulu University Hospital, Oulu, Finland
- Finnish Institute of Occupational Health, Oulu, Finland
| | - Dino Samartzis
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR China
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Coutinho MAC, Pratali RDR, Motta MMD, Hoffman CB, Barsotti CEG, Santos FPED, Oliveira CEASD. INFLUENCE OF THE SAGITTAL BALANCE ON THE CLINICAL OUTCOME IN SPINAL FUSION. COLUNA/COLUMNA 2016. [DOI: 10.1590/s1808-185120161501153517] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: Evaluates which radiographic parameters of the sagittal and spinopelvic balance influence the clinical and functional outcomes of a sample of patients undergoing spinal fusion. Methods: We studied 32 patients who underwent spinal fusion. Radiographs of the total spine were obtained from all patients. The clinical and functional parameters studied were analysis of pain by visual analogic scale (VAS) and Oswestry and SRS-30 questionnaires. We analyzed the correlation between the clinical and functional parameters and radiographic parameters of the sagittal and spinopelvic balance. Results: There was no significant correlation between parameters pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL) and difference between PI and LL (PI-LL) and clinical parameters (p > 0.05 and r <0.2). Significant correlation were identified only between Sagittal Vertical Axis (SVA) and Satisfaction with Treatment domain of SRS-30 (r = 0.402 e p = 0.023) and between thoracic kyphosis (TK) and the total SRS-30 (r = 0.419 and p = 0.017). Conclusions: According to the study results, it was not possible to precisely characterize the role of the parameters of the sagittal and spinopelvic balance in the post-operative analysis of the clinical outcome of spinal fusion. There was a significant correlation only between SVA and the Satisfaction with Treatment domain of SRS-30 and between TK and total SRS-30.
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Uysal E, Paksoy Y, Koplay M, Nayman A, Gumus S. Effects of body mass index, mesenteric and abdominal subcutaneous adipose tissue on the spinopelvic parameters. Wien Klin Wochenschr 2015; 127:935-41. [DOI: 10.1007/s00508-015-0851-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 08/11/2015] [Indexed: 10/23/2022]
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Lumbar lordosis and sacral slope in lumbar spinal stenosis: standard values and measurement accuracy. Arch Orthop Trauma Surg 2015; 135:607-12. [PMID: 25750110 DOI: 10.1007/s00402-015-2184-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Indexed: 10/23/2022]
Abstract
STUDY DESIGN Radiological study. PURPOSE To asses standard values, intra- and interobserver reliability and reproducibility of sacral slope (SS) and lumbar lordosis (LL) and the correlation of these parameters in patients with lumbar spinal stenosis (LSS). METHODS Anteroposterior and lateral X-rays of the lumbar spine of 102 patients with LSS were included in this retrospective, radiologic study. Measurements of SS and LL were carried out by five examiners. Intraobserver correlation and correlation between LL and SS were calculated with Pearson's r linear correlation coefficient and intraclass correlation coefficients (ICC) were calculated for inter- and intraobserver reliability. In addition, patients were examined in subgroups with respect to previous surgery and the current therapy. RESULTS Lumbar lordosis averaged 45.6° (range 2.5°-74.9°; SD 14.2°), intraobserver correlation was between Pearson r = 0.93 and 0.98. The measurement of SS averaged 35.3° (range 13.8°-66.9°; SD 9.6°), intraobserver correlation was between Pearson r = 0.89 and 0.96. Intraobserver reliability ranged from 0.966 to 0.992 ICC in LL measurements and 0.944-0.983 ICC in SS measurements. There was an interobserver reliability ICC of 0.944 in LL and 0.990 in SS. Correlation between LL and SS averaged r = 0.79. No statistically significant differences were observed between the analyzed subgroups. CONCLUSION Manual measurement of LL and SS in patients with LSS on lateral radiographs is easily performed with excellent intra- and interobserver reliability. Correlation between LL and SS is very high. Differences between patients with and without previous decompression were not statistically significant.
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Maillot C, Ferrero E, Fort D, Heyberger C, Le Huec JC. Reproducibility and repeatability of a new computerized software for sagittal spinopelvic and scoliosis curvature radiologic measurements: Keops®. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24:1574-81. [DOI: 10.1007/s00586-015-3817-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 02/14/2015] [Accepted: 02/14/2015] [Indexed: 10/23/2022]
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The reliability of sagittal pelvic parameters: the effect of lumbosacral instrumentation and measurement experience. Spine (Phila Pa 1976) 2015; 40:E253-8. [PMID: 25494319 DOI: 10.1097/brs.0000000000000720] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Sagittal pelvic parameters (SPPs) of a representative patient sample drawn from a consecutive adult spinal deformity database were measured using Surgimap Spine. Estimated coefficient of reliability intraclass coefficient (95% confidence interval), standard error of measurement, and mean absolute deviation were used for the analysis. OBJECTIVE The primary objective of this study was to assess the reliability of SPP measurements using Surgimap Spine. The secondary objective was to evaluate the impact of pelvic instrumentation as well as the impact of user expertise. SUMMARY OF BACKGROUND DATA The radiographical measurement of SPP is increasingly recognized as playing a critical role in establishing the surgical goals and surgical strategy of many spinal disorders. Although instrumented flatback is a common cause of sagittal malalignment, to our knowledge, SPP measurement reliability has never been assessed in instrumented spines. METHODS Sixty-three adult full-spine standing lateral radiographs (31 with lumbosacral instrumentation) were measured twice by 13 observers using Surgimap Spine. Observers were stratified into 3 levels of experience: high (research coordinators, 4), mid (senior surgeons, 5), and low (junior surgeons, 4). Research coordinators trained all surgeons for less than 30 minutes. Parameters measured were pelvic incidence, pelvic tilt, and sacral slope. RESULTS Thirteen observers and 63 radiographs generated 817 observations (2 misses). Overall inter- and intraobserver reliability of SPP measurement was excellent (intraclass coefficient > 0.85). Lumbosacral instrumentation did not modify intraobserver reliability but reduced significantly interobserver reliability of pelvic tilt (P = 0.006) and sacral slope (P = 0.007). Experience did not affect intraobserver reliability but interobserver reliability of highly experienced observers was significantly lower (P < 0.05) than among less experienced observers. CONCLUSION Measurement of SPP using Surgimap Spine equals or improves previously reported reliability data. Lumbosacral instrumentation reduces interobserver reliability taking it from excellent to moderate in the sacral slope measurement. Inexperienced observers can measure SPP reliably after a short tutorial. LEVEL OF EVIDENCE 4.
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Vining RD, Potocki E, McLean I, Seidman M, Morgenthal AP, Boysen J, Goertz C. Prevalence of radiographic findings in individuals with chronic low back pain screened for a randomized controlled trial: secondary analysis and clinical implications. J Manipulative Physiol Ther 2014; 37:678-87. [PMID: 25455834 DOI: 10.1016/j.jmpt.2014.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 08/16/2014] [Accepted: 09/01/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The purpose of this study is to measure the prevalence of graded disc degeneration, spondylolisthesis, transitional segmentation, and the distribution of sacral slope in patients 21 to 65 years of age with chronic low back pain (CLBP). METHODS This retrospective study analyzed 247 digital lumbar radiographic series obtained during a randomized controlled trial of chiropractic patients with CLBP. Chronic low back pain was defined as pain in the low back lasting 12 weeks or longer. Radiographic findings of disc degeneration, spondylolisthesis, and lumbosacral transitional segmentation were graded by 2 authors using established classification criteria. Sacral slope was measured with a digital tool contained within imaging software. RESULTS Lumbosacral transitional segments graded I to IV (Castellvi classification) were present in 14% of cases. Lumbar disc degeneration was most prevalent at L3-4 (49%), followed by L4-5 (42%), L2-3 (41%), L5-S1 (37%), and L1-2 (29%). Isthmic spondylolisthesis was present in 5% of cases, with L5 the most common location. Degenerative spondylolisthesis demonstrated a prevalence of 18%, most commonly occurring at L4. The prevalence of degenerative spondylolisthesis was 51% for women aged 50 to 59 years and 24% for men in the same age range. CONCLUSIONS Moderate-severe disc degeneration, multilevel disc narrowing, and degenerative spondylolisthesis were common in individuals with CLBP with age more than 40 years. Isthmic spondylolisthesis was not more prevalent than what has been reported in other populations. Transitional segmentation was identified in a minority of participants, with some of these exhibiting accessory joints or fusion. Mean sacral slope in individuals with CLBP was not substantially different from mean slopes reported in other populations.
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Affiliation(s)
- Robert D Vining
- Associate Professor, Senior Research Clinician, Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA.
| | - Eric Potocki
- Research Clinician, Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA
| | - Ian McLean
- Professor, Director of Clinical Radiology, Palmer College of Chiropractic, Davenport, IA
| | - Michael Seidman
- Research Clinician, Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA
| | - A Paige Morgenthal
- Research Clinician, Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA
| | - James Boysen
- Study Coordinator, Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA
| | - Christine Goertz
- Vice Chancellor for Research and Health Policy, Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA
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Bernard JC, Deceuninck J, Leroy-Coudeville S, Loustalet E, Morel E, Combey A, Sutton J, Berthonnaud E, Chaléat-Valayer E. Motor function levels and pelvic parameters in walking or ambulating children with cerebral palsy. Ann Phys Rehabil Med 2014; 57:409-21. [PMID: 25127064 DOI: 10.1016/j.rehab.2014.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 06/04/2014] [Accepted: 06/04/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND In children with cerebral palsy, spinal equilibrium and pelvic strategies may vary according to the functional status. OBJECTIVES To study the relationship between motor function and pelvic and spinal parameters in a population of children and adolescents with cerebral palsy (rated from level I to level IV on Gross Motor Function Classification System [GMFCS]). A sagittal X-ray of the spine in the standing position was analyzed with Optispine(®) software. RESULTS The study population comprised 114 children and adolescents (mean [range] age: 12.35 [4-17]). For the study population as a whole, there were significant overall correlations between the GMFCS level on one hand and pelvic incidence and pelvic tilt (PT) on the other (P=0.013 and 0.021, respectively). DISCUSSION Pelvic parameters vary according to the GMFCS level but do not appear to affect spinal curvature. The sacrum is positioned in front of the head of the femur (i.e. negative PT) in GMFCS level I and progressively moves backwards (i.e. positive PT) in GMFCS levels II, III and IV.
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Affiliation(s)
- J-C Bernard
- Service de MPR pédiatrique, Croix-Rouge française, centre médico-chirurgical de réadaptation des massues, 92, rue Édmond-Locard, 69322 Lyon cedex 05, France.
| | - J Deceuninck
- Service de MPR pédiatrique, Croix-Rouge française, centre médico-chirurgical de réadaptation des massues, 92, rue Édmond-Locard, 69322 Lyon cedex 05, France; Laboratoire de physiologie de l'exercice, université de Lyon, Saint-Étienne, France
| | - S Leroy-Coudeville
- Service de MPR pédiatrique, Croix-Rouge française, centre médico-chirurgical de réadaptation des massues, 92, rue Édmond-Locard, 69322 Lyon cedex 05, France
| | - E Loustalet
- Service de MPR pédiatrique, Croix-Rouge française, centre médico-chirurgical de réadaptation des massues, 92, rue Édmond-Locard, 69322 Lyon cedex 05, France
| | - E Morel
- Service de MPR pédiatrique, Croix-Rouge française, centre médico-chirurgical de réadaptation des massues, 92, rue Édmond-Locard, 69322 Lyon cedex 05, France
| | - A Combey
- Service de MPR pédiatrique, Croix-Rouge française, centre médico-chirurgical de réadaptation des massues, 92, rue Édmond-Locard, 69322 Lyon cedex 05, France
| | - J Sutton
- Service de MPR pédiatrique, Croix-Rouge française, centre médico-chirurgical de réadaptation des massues, 92, rue Édmond-Locard, 69322 Lyon cedex 05, France
| | - E Berthonnaud
- Hôpital Nord Ouest, Villefranche-sur-Saône, France; Laboratoire de physiologie de l'exercice, université de Lyon, Saint-Étienne, France
| | - E Chaléat-Valayer
- Service de MPR pédiatrique, Croix-Rouge française, centre médico-chirurgical de réadaptation des massues, 92, rue Édmond-Locard, 69322 Lyon cedex 05, France
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Influence of implant rod curvature on sagittal correction of scoliosis deformity. Spine J 2014; 14:1432-9. [PMID: 24275616 DOI: 10.1016/j.spinee.2013.08.042] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 06/27/2013] [Accepted: 08/23/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Deformation of in vivo-implanted rods could alter the scoliosis sagittal correction. To our knowledge, no previous authors have investigated the influence of implanted-rod deformation on the sagittal deformity correction during scoliosis surgery. PURPOSE To analyze the changes of the implant rod's angle of curvature during surgery and establish its influence on sagittal correction of scoliosis deformity. STUDY DESIGN A retrospective analysis of the preoperative and postoperative implant rod geometry and angle of curvature was conducted. PATIENT SAMPLE Twenty adolescent idiopathic scoliosis patients underwent surgery. Average age at the time of operation was 14 years. OUTCOME MEASURES The preoperative and postoperative implant rod angle of curvature expressed in degrees was obtained for each patient. METHODS Two implant rods were attached to the concave and convex side of the spinal deformity. The preoperative implant rod geometry was measured before surgical implantation. The postoperative implant rod geometry after surgery was measured by computed tomography. The implant rod angle of curvature at the sagittal plane was obtained from the implant rod geometry. The angle of curvature between the implant rod extreme ends was measured before implantation and after surgery. The sagittal curvature between the corresponding spinal levels of healthy adolescents obtained by previous studies was compared with the implant rod angle of curvature to evaluate the sagittal curve correction. The difference between the postoperative implant rod angle of curvature and normal spine sagittal curvature of the corresponding instrumented level was used to evaluate over or under correction of the sagittal deformity. RESULTS The implant rods at the concave side of deformity of all patients were significantly deformed after surgery. The average degree of rod deformation Δθ at the concave and convex sides was 15.8° and 1.6°, respectively. The average preoperative and postoperative implant rod angle of curvature at the concave side was 33.6° and 17.8°, respectively. The average preoperative and postoperative implant rod angle of curvature at the convex side was 25.5° and 23.9°, respectively. A significant relationship was found between the degree of rod deformation and preoperative implant rod angle of curvature (r=0.60, p<.005). The implant rods at the convex side of all patients did not have significant deformation. The results indicate that the postoperative sagittal outcome could be predicted from the initial rod shape. CONCLUSIONS Changes in implant rod angle of curvature may lead to over- or undercorrection of the sagittal curve. Rod deformation at the concave side suggests that corrective forces acting on that side are greater than the convex side.
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Barroqueiro C, Morais NV. The effects of a global postural reeducation program on an adolescent handball player with isthmic spondylolisthesis. J Bodyw Mov Ther 2014; 18:244-58. [DOI: 10.1016/j.jbmt.2013.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 09/17/2013] [Accepted: 09/17/2013] [Indexed: 11/29/2022]
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Montgomery RA, Hresko MT, Kalish LA, Gold M, Li Y, Haus B, Glotzbecker M, Berthonnaud E. Spondylolisthesis: Intra-rater and Inter-rater Reliabilities of Radiographic Sagittal Spinopelvic Parameters Using Standard Picture Archiving and Communication System Measurement Tools. Spine Deform 2013; 1:412-418. [PMID: 27927366 DOI: 10.1016/j.jspd.2013.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 06/10/2013] [Accepted: 07/15/2013] [Indexed: 10/26/2022]
Abstract
STUDY DESIGN Reliability analysis. OBJECTIVE To determine the intra-rater and inter-rater reliability of common sagittal spinopelvic measurements from Digital Imaging and Communications in Medicine images on a commercial Picture Archiving and Communication system for patients with developmental spondylolisthesis. SUMMARY OF BACKGROUND DATA Computer-aided analysis of digital radiographs has been used in research protocols to define anatomic and positional characteristics of developmental spondylolisthesis. Previous studies have shown poor reliability and weak correlations of manual measurements used in clinical practice with research measurements, which limit the clinical value of prior research. METHODS Five raters of varying experience measured lateral spinopelvic images of 30 patients with developmental spondylolisthesis. Measurements were repeated after 1 week. Intra-rater and inter-rater reliabilities for each measurement were determined. Measurements were compared with those obtained from a computer-based image enhancement research system. Continuous variables were assessed by analysis of variance, whereas kappa statistics were determined for categorical variables. RESULTS Excellent intraclass correlations (ICC)s were obtained for all radiographic measurements based on linear values (slip ratio and C7 balance) as well as pelvic tilt angle. Angular measurements had good to excellent ICC but were weaker when the sacral plate was involved. There was poor agreement with classification of sacral doming. Some measurements had reduced reliability in the images with evidence of doming. CONCLUSIONS Excellent ICCs were found with measurements of from Digital Imaging and Communications in Medicine images using commercial Picture Archiving and Communication System tools. Sacral doming affected the reliability. A radiographic classification of spondylolisthesis will be most reliable when based on slip ratio, C7 balance, and pelvic tilt.
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Affiliation(s)
| | - M Timothy Hresko
- Department of Orthopaedics, Children's Hospital Boston, Department of Orthopaedic Surgery, Children's Hospital Boston, 300 Longwood Avenue, Boston, Massachusetts, 02115, USA.
| | - Leslie A Kalish
- Clinical Research Center, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Meryl Gold
- Department of Orthopaedics, Children's Hospital Boston, Department of Orthopaedic Surgery, Children's Hospital Boston, 300 Longwood Avenue, Boston, Massachusetts, 02115, USA
| | - Ying Li
- Department of Orthopaedics, Children's Hospital Boston, Department of Orthopaedic Surgery, Children's Hospital Boston, 300 Longwood Avenue, Boston, Massachusetts, 02115, USA
| | - Brian Haus
- Department of Orthopaedics, Children's Hospital Boston, Department of Orthopaedic Surgery, Children's Hospital Boston, 300 Longwood Avenue, Boston, Massachusetts, 02115, USA
| | - Michael Glotzbecker
- Department of Orthopaedics, Children's Hospital Boston, Department of Orthopaedic Surgery, Children's Hospital Boston, 300 Longwood Avenue, Boston, Massachusetts, 02115, USA
| | - Eric Berthonnaud
- L'Hôpital Nord Ouest, Site de Villefranche/Saône, BP 436, 69655 Villefranche/Saône Cedex, France
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Oh YM, Eun JP. The relationship between sagittal spinopelvic parameters and the degree of lumbar intervertebral disc degeneration in young adult patients with low-grade spondylolytic spondylolisthesis. Bone Joint J 2013; 95-B:1239-43. [DOI: 10.1302/0301-620x.95b9.31717] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We investigated the relationship between spinopelvic parameters and disc degeneration in young adult patients with spondylolytic spondylolisthesis. A total of 229 men with a mean age of 21 years (18 to 26) with spondylolytic spondylolisthesis were identified. All radiological measurements, including pelvic incidence, sacral slope, pelvic tilt, lumbar lordosis, sacral inclination, lumbosacral angle (LSA), and sacrofemoral distance, were calculated from standing lateral lumbosacral radiographs. The degree of intervertebral disc degeneration was classified using a modified Pfirrmann scale. We analysed the spinopelvic parameters according to disc level, degree of slip and disc degeneration. There were significant positive correlations between the degree of slip and pelvic incidence (p = 0.009), sacral slope (p = 0.003) and lumbar lordosis (p = 0.010). The degree of slip and the LSA were correlated with disc degeneration (p < 0.001 and p = 0.003, respectively). There was also a significant difference between the degree of slip (p < 0.001) and LSA (p = 0.006) according to the segmental level of disc degeneration. Cite this article: Bone Joint J 2013;95-B:1239–43.
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Affiliation(s)
- Y-M. Oh
- Chonbuk National University Medical School
and Hospital, Department of Neurosurgery, Research
Institute of Clinical Medicine, 20 Geonji-ro
Deokjin-gu Jeonju, Chonbuk 561-712, South
Korea
| | - J-P. Eun
- Chonbuk National University Medical School
and Hospital, Department of Neurosurgery, Research
Institute of Clinical Medicine, 20 Geonji-ro
Deokjin-gu Jeonju, Chonbuk 561-712, South
Korea
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Bernard JC, Deceuninck J, Combey A, Berthonnaud E. Radiological parameters of sagittal plane in children with cerebral palsy, walking or wandering. SCOLIOSIS 2013. [PMCID: PMC3675413 DOI: 10.1186/1748-7161-8-s1-p17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Golbakhsh MR, Hamidi MA, Hassanmirzaei B. Pelvic incidence and lumbar spine instability correlations in patients with chronic low back pain. Asian J Sports Med 2013; 3:291-6. [PMID: 23342229 PMCID: PMC3525827 DOI: 10.5812/asjsm.34554] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 07/08/2012] [Indexed: 11/30/2022] Open
Abstract
Purpose Many factors such as lumbar instability and spinopelvic alignment are associated with low back pain. Our purpose was to analyze the pelvic incidence - one of spinopelvic alignment parameters- and spine instability correlations in patients with chronic low back pain. Methods Fifty-two patients suffering from chronic low back pain entered this case control study. Lateral spine radiography was taken from patients. pelvic incidence and L3, L4 and L5‘s vertebral body width were measured for all patients, and lumbar instability was evaluated in 3 different levels: L5-S1, L4-L5 and L3-L4. Results Thirty-two patients having lumbar instability formed group A and 20 patients without lumbar spine instability allocated to group B. Average age, mean weight, height, body mass index and mean vertebral width of both groups did not differ meaningfully. Pelvic incidence‘s mean amounts set to 53.9 in group B and 57.7 in group A without any significant difference; but pelvic incidence was significantly lower in patients with lumbar instability of L5-S1 origin (P=0.01). Conclusions Overall, pelvic incidence did not differ between two groups. However, separate evaluation of each level revealed lumbar instability of L5-S1 segment to be associated with lower pelvic incidence.
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Affiliation(s)
| | | | - Bahar Hassanmirzaei
- Sports Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Address: Sports Medicine Research Center, No 6, Al-e-Ahmad Highway, Tehran, Iran. P.O. BOX: 14395-578.
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Deceuninck J, Bernard JC, Combey A, Leroy-Coudeville S, Morel E, Loustalet E, Chaleat-Valayer E, Berthonnaud E. Sagittal X-ray parameters in walking or ambulating children with cerebral palsy. Ann Phys Rehabil Med 2013; 56:123-33. [PMID: 23318160 DOI: 10.1016/j.rehab.2012.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 11/27/2012] [Accepted: 11/29/2012] [Indexed: 10/27/2022]
Abstract
Adolescents with cerebral palsy (CP) who walk or ambulate often have an abnormal clinical and radiological spinal profile during pubertal growth compared with adolescents of the same age without neuromotor impairments. Therefore, in the following study, we aimed to conduct a radiological assessment of static data on the lumbar-pelvic-femoral complex in ambulatory children with CP to compare these data with those of an asymptomatic population. The CP population was comprised of 119 children and the asymptomatic population was comprised of 652 children. The large format (30×90cm) sagittal X-rays were taken while subjects were in a comfortable position in which knees and hips were in maximal extension. Analyses were performed using Optispine(®) software to measure the parameters of an X-ray of the profile of the spine, pelvis and femurs. Comparing, the two populations, we found no difference in the shape parameter (pelvic incidence) but we did find significant differences in the positional parameters (pelvic tilt and sacral slope) of the pelvis. We found a difference in the curvature and orientation of lumbar lordosis as well as in the number of vertebrae involved in the kyphosis and its orientation. There was also a significant difference in the C7 plumb line. We can say that the CP population is not structurally different from the control population, but that parameters become disturbed during growth. These disturbances should be identified and monitored so that changes can be detected early and progression can be prevented.
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Affiliation(s)
- J Deceuninck
- Croix-Rouge française, CMCR des Massues, 92, rue du Dr-Edmond-Locard, 69005 Lyon, France.
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Romero-Vargas S, Zárate-Kalfópulos B, Otero-Cámara E, Rosales-Olivarez L, Alpízar-Aguirre A, Morales-Hernández E, Reyes-Sánchez A. The impact of body mass index and central obesity on the spino-pelvic parameters: a correlation study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 22:878-82. [PMID: 23149493 DOI: 10.1007/s00586-012-2560-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2011] [Revised: 06/06/2012] [Accepted: 10/28/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Obesity is an increasing problem of epidemic proportion, and it is associated with various musculoskeletal disorders, including impairment of the spine. However, the relationship between obesity and spino-pelvic parameters remains to date unsupported by an objective measurement of the mechanical behavior of the spino-pelvic parameters depending on body mass index (BMI) and the presence of central obesity. Such analysis may provide a deeper understanding of this relationship. PURPOSE To assess whether BMI and central obesity are associated with modifications on spino-pelvic parameters and determine if exists any correlation between BMI and obesity with the type of lumbar lordosis (LL). METHODS A cross-sectional study with 200 participants was conducted. Parameters measured were LL, pelvic tilt, sacral slope, and pelvic incidence (PI), using lumbosacral radiographs in lateral view. Subjects were classified depending on BMI. In a secondary analysis, the subjects were categorized into two groups depending on the presence or not of elevated abdominal circumference. The categorical variables were compared using Chi-square test, and the mean values were compared using ANOVA and student t test. A Spearman correlation test was used to analyze the correlation between BMI categories and LL types. RESULTS From the total of participants, there were 51 (25.5 %) normal weight subjects, 93 (46.5 %) overweight, and 56 (28 %) obese individuals. The spino-pelvic parameters among these groups are practically equal. The correlation between the different BMI categories and LL types is poor 0.06 (P = 0.34). In a secondary analysis, grouping the participants in obese and non-obese, the results showed that obesity is modestly positively associated with increasing of spino-pelvic parameters values, in particular with PI (P = 0.078). The comparison made between the presence or not of central obesity, interestingly did not show significant differences. CONCLUSIONS Despite the results did not reach statistically significant differences, the results indicate that the obese spine is slightly different from the non-obese spine. Therefore, this relationship deserves future attention.
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Affiliation(s)
- S Romero-Vargas
- Spine Surgery Service, Instituto Nacional de Rehabilitación, Calzada México Xochimilco #289 Col. Arenal de Guadalupe, Zip Code 14389, Mexico City, Mexico
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BERTHONNAUD E, FOUGIER P, HILMI R, LABELLE H, DIMNET J. RELATIONSHIP BETWEEN SAGITTAL SPINAL CURVES AND BACK SURFACE PROFILES OBTAINED WITH RADIOGRAPHS. J MECH MED BIOL 2012. [DOI: 10.1142/s0219519410003381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The purpose of this article is to introduce a novel approach, by using coupled video and radiographic analysis of back surface and spinal curves in the sagittal plane to decrease the ionizing radiation exposure for subjects requiring long-term follow-up of their spinal deformity. This approach is specifically designed for the use in a clinical set-up for the follow-up of subjects with progressive spinal deformities. The subjects are radiographed with nine steel balls embedded in circular markers evenly distributed on the subject's back surface over the spinous processes of C7 to S1. A technique allows to draw the external back profile and the spinal curve. Patient-specific transfer functions are defined moving the back profile to the spinal curve. Sixteen adult volunteers were tested to validate the concepts proposed. For each of them, the values of transfer functions between radiographic back surface profile and corresponding spinal curve have been calculated. Each internal curve is correctly simulated when based upon the back profile. Our research is now focused on the prediction of the internal curve of patients from their back surface profile based on patient-specific transfer functions.
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Affiliation(s)
- E. BERTHONNAUD
- DIM, Centre Hospitalier de Villefranche sur Saône, BP 80436, 69655 Villefranche Cedex, France
- Group of Applied Research in Orthopaedic, Lyon, France
| | - P. FOUGIER
- Division of Medical Imaging, Centre Hospitalier de Villefranche sur Saône, France
| | - R. HILMI
- Division of Orthopaedics, Centre Hospitalier de Villefranche sur Saône, France
| | - H. LABELLE
- Division of Orthopaedics, University of Montreal, Hôpital Sainte Justine, Montreal, Canada
| | - J. DIMNET
- Group of Applied Research in Orthopaedic, Lyon, France
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Kim CH, Chung CK, Hong HS, Kim EH, Kim MJ, Park BJ. Validation of a simple computerized tool for measuring spinal and pelvic parameters. J Neurosurg Spine 2012; 16:154-62. [DOI: 10.3171/2011.10.spine11367] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Recent studies have emphasized measuring the sagittal vertical axis (SVA) and pelvic parameters (pelvic incidence, sacral slope, and pelvic tilt) when evaluating spinal disorders. An accurate and reproducible measurement is important for a reliable result. Although computerized measurement is more consistent than manual measurement, computerized measurement requires an expensive software program, the need to transfer images to a workstation, and additional education for users. An inexpensive and convenient computerized measurement program is desirable and necessary. The object of this study was to propose a computerized tool for measuring spinal and pelvic parameters and to evaluate the efficacy of this new tool compared with manual measurement.
Methods
The authors devised a tool that provides computerized measurements of the SVA and pelvic parameters in a picture archiving and communication system (PACS) without transferring images to another program. This tool was created by merging functions in the PACS. The resulting tool is easy to implement by merging functions (indicate the center of 2 points, plot a vertical and a horizontal line from a point, and measure the angles between lines) in any image viewer. The tool was made into icons on a toolbar in the PACS. Measurements of distance and angle were computerized by identifying crucial points after selecting the icon. For SVA, 4 points were identified around each corner of the C-7 body and a fifth point at the superior/posterior corner of the S-1 body. For pelvic parameters, 4 points were identified at the centers of each femoral head and at the anterior/superior and posterior/superior corners of S-1. Thirty-three whole-spine lateral radiographs were randomly selected from the radiographic database. To evaluate inter- and intraobserver variability between observers and method, skilled (2 years of experience) and unskilled (1 week of experience) observers measured SVA and pelvic parameters 3 times with a 7-day interval between each time using both computerized and manual measurement methods. The reliability was measured using the intraclass correlation coefficient.
Results
The computerized method showed better congruity than the manual method in both skilled and unskilled observers (p < 0.05), and the intraclass correlation coefficients were > 0.9. The skilled observer showed better agreement than the unskilled observer with both computerized and manual methods, and this difference was prominent in measuring pelvic parameters (p < 0.05). The computerized method required less time than the manual method, especially for the unskilled observer (p < 0.05).
Conclusions
A computerized measurement of pelvic parameters may be a more reliable and efficacious approach than manual measurements. This benefit is more prominent in the unskilled observer, and adding this simple function to an image viewer may be recommended in future studies.
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Affiliation(s)
- Chi Heon Kim
- 1Department of Neurosurgery, Seoul National University College of Medicine
- 2Neuroscience Research Institute, Seoul National University Medical Research Center
- 3Clinical Research Institute, Seoul National University Hospital
| | - Chun Kee Chung
- 1Department of Neurosurgery, Seoul National University College of Medicine
- 2Neuroscience Research Institute, Seoul National University Medical Research Center
- 3Clinical Research Institute, Seoul National University Hospital
| | - Hee Suk Hong
- 1Department of Neurosurgery, Seoul National University College of Medicine
| | - Eun Hyun Kim
- 1Department of Neurosurgery, Seoul National University College of Medicine
| | - Min Jung Kim
- 4Medical Research Collaborating Center, Seoul National University Hospital, Seoul National University College of Medicine; and
| | - Byung Joo Park
- 4Medical Research Collaborating Center, Seoul National University Hospital, Seoul National University College of Medicine; and
- 5Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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Sergides IG, McCombe PF, White G, Mokhtar S, Sears WR. Lumbo-pelvic lordosis and the pelvic radius technique in the assessment of spinal sagittal balance: strengths and caveats. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 20 Suppl 5:591-601. [PMID: 21863464 DOI: 10.1007/s00586-011-1926-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 07/11/2011] [Indexed: 01/04/2023]
Abstract
INTRODUCTION The two main methodologies described for the assessment of spinal sagittal alignment are the pelvic radius (PR) technique and that based on measures of the Pelvic Incidence (PI) and Spino-Sacral Angle (SSA). Both methods stress the fundamental relationship between the anatomical position and orientation of the sacrum within the pelvis and the spinal curves above. The aim of the current study was to assess the strengths and potential weaknesses of the PR technique. The PR technique uses measures based on a line (the PR), drawn between the hip axis and the posterior corner of the S1 endplate. The angle formed between the PR line and the sacral endplate, PRS1, is a developmental measure of sacropelvic morphology. Geometrically, PI and PRS1 are approximately complementary angles and both reflect reciprocal alterations in pelvic tilt (for PI) or angulation (for PRS1) and the slope of the S1 endplate. The angle formed between PR and T12, the PR-T12, reflects a combined measure of pelvic morphology and lumbar lordosis. It appears to be a useful measure, which provides a simple and rapid assessment of lumbopelvic sagittal balance, but only in the presence of a congruent thoracic curvature. MATERIALS AND METHODS After reviewing the literature, published measures made using the PR technique were compared to measures taken from a substantial patient population (479 adult patients). CONCLUSIONS Errors can occur using the PR technique if the PRT12 is viewed in isolation from the thoracic kyphosis. We found the ratio of the thoracic kyphosis to lumbar lordosis (T4-T12/T12-S1) to be a useful predictor of congruent sagittal alignment, which may alert the clinician to situations where use of the PR-T12 in isolation may be misleading.
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Pellet N, Aunoble S, Meyrat R, Rigal J, Le Huec JC. Sagittal balance parameters influence indications for lumbar disc arthroplasty or ALIF. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 20 Suppl 5:647-62. [PMID: 21845396 DOI: 10.1007/s00586-011-1933-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 07/11/2011] [Indexed: 11/28/2022]
Abstract
UNLABELLED Chronic lower back pain is a potentially incapacitating condition associated with disc degeneration. Although therapy is primarily pharmaceutical, surgery comprising arthrodesis constitutes an alternative. Anterior intersomatic lumbar arthrodesis (ALIF, anterior interbody lumbar fusion) is the reference approach, although total disc arthroplasty may also be undertaken. Analysis of pelvic and spinal parameters provides the best indication of sagittal balance. MATERIALS AND METHODS This was a prospective study in a continuous series of 99 patients presenting chronic lower back pain due to disc disease. Pelvic incidence, sacral slope, pelvic tilt, spino-sacral angle (SSA) and the four back types in the Roussouly classification were studied in radiographs of the whole spine under load using an EOS imaging system. RESULTS The pre-operative SSA value for the study population was 126.09° ± 8.45° and the mean spine tilt angle was 90° compared with 95° in healthy subjects. Following surgery, the SSA was considerably increased in the discal arthroplasty, resulting in a significantly more balanced spinal position. In the group of patients undergoing arthrodesis using the ALIF technique, no such significant improvement was found despite the use of a lordosis cage. We showed that in cases of low pelvic incidence, it was necessary to maintain a Roussouly type 1 or 2 back without increasing lordosis. The results demonstrated the value of L4-L5 disc prostheses in these subjects. L5-S1 arthrodesis seemed a more suitable approach for treating patients with elevated sacral slope (back type 3 or 4). This new type of analysis of sagittal parameters should be performed prior to all surgical procedures involving lumbar prostheses.
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Affiliation(s)
- N Pellet
- Spine Unit 2, CHU Pellegrin, Orthopaedic Department, University of Bordeaux, 33076, Bordeaux, France
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Mac-Thiong JM, Roussouly P, Berthonnaud E, Guigui P. Age- and sex-related variations in sagittal sacropelvic morphology and balance in asymptomatic adults. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 20 Suppl 5:572-7. [PMID: 21833574 DOI: 10.1007/s00586-011-1923-2] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 07/11/2011] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Many studies suggest the importance of the sagittal sacropelvic balance and morphology in spinal and hip disorders. This study describes the normal age- and sex-related changes in sacropelvic morphology and balance in a prospective cohort of asymptomatic adults without spinal disorder. MATERIALS AND METHODS A prospective cohort of 709 asymptomatic adults without spinal pathology was recruited. There were 354 males and 355 females aged 37.9 ± 14.7 and 35.7 ± 13.9 years, respectively. For each subjects, pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) were measured from standing lateral radiographs. Ratios of SS to PI (SS/PI), PT to PI (PT/PI), and PT to SS (PT/SS) were also calculated. RESULTS There was no significant difference in PI (pelvic incidence), SS (sacral slope), PT (pelvic tilt), PT/PI, SS/PI, or PT/SS between males and females. The mean ± 2 standard deviations (SD) range was 32°-74°, 0°-27°, and 24°-55° for PI, PT and SS, respectively. The mean ± 2 SD range was greater than 0.5 for SS/PI and less than 0.5 for PT/PI. PI was not related to age in either sex group. PT, SS, PT/PI, SS/PI, and PT/SS presented only weak correlation coefficients (r ≤ 0.21) with respect to age. CONCLUSION The current study presents the largest cohort of asymptomatic adults in the literature dedicated to the evaluation of sagittal sacropelvic morphology and balance. The range of values corresponding to the mean ± 2 SD can provide invaluable information to clinicians about the normal range of values expected in 95% of the normal population.
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Sagittal parameters of global spinal balance: normative values from a prospective cohort of seven hundred nine Caucasian asymptomatic adults. Spine (Phila Pa 1976) 2010; 35:E1193-8. [PMID: 20959772 DOI: 10.1097/brs.0b013e3181e50808] [Citation(s) in RCA: 144] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective study of normal sagittal global spinal balance in the Caucasian adult population. OBJECTIVE To document values for parameters of global spinal balance in 709 asymptomatic adults without spinal pathology. SUMMARY OF BACKGROUND DATA Previous studies have investigated sagittal spinal balance in the normal population, but there is still a need for a large prospective database with normative values on the basis of gender and age. METHODS Spinosacral angle (SSA), spinal tilt (ST), and C7 translation ratio were evaluated in 709 asymptomatic adults (354 males and 355 females). Position of C7 plumbline relative to sacrum and hip axis (HA) was also assessed. Comparisons on the basis of gender were performed using analyses of covariance with age as covariate. Relationships between parameters and age were assessed using Spearman's coefficients. RESULTS Mean SSA, ST, and C7 translation ratio were respectively 130.4° ± 8.1°, 90.8° ± 3.4°, and 0.1° ± 1.9°. Mean ± 2 standard deviations were respectively 110° to 150° for SSA and 85° to 100° for ST. Mean SSA and ST were higher in females but by less than 2°. C7 plumbline was behind the HA in 86% of subjects. Correlations between global balance and age were small (-0.1 ≤ r ≤ 0.1), with only 1 correlation reaching statistical significance (SSA vs. age; r = -0.1), reflecting a slight tendency for SSA to decrease with age. There was no relationship between ST and age. CONCLUSION Asymptomatic adults tend to stand with a stable global balance and it is expected that 95% of normal adults have an SSA and ST between 110° to 150° and 85° to 100°, respectively. C7 plumbline in front of the HA is not necessarily associated with a spinal pathology. Results suggest that in adults, anterior displacement of C7 plumbline with respect to sacrum cannot be attributed solely to aging and should raise a suspicion for the risk of developing spinal pathology.
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Abstract
STUDY DESIGN Comparison of 2 radiographic measurement techniques of slip severity in spondylolisthesis. OBJECTIVE To analyze the differences between 2 radiologic measurement techniques of slip severity in L5-S1 developmental spondylolisthesis. SUMMARY OF BACKGROUND DATA Different techniques for the assessment of slip in spondylolisthesis have been described in the literature, resulting in 2 different methods to report the position of the L5 vertebra on the S1 superior endplate. The clinical impact of these differences in slip measurement is unknown. METHODS Radiographs of 130 subjects with developmental spondylolisthesis were reviewed. Two different techniques were used to assess the grade and percentage of slip. The technique 1 uses a line drawn from the L5 vertebra postero-inferior corner that is perpendicular to the S1 vertebra endplate. The technique 2 uses a line tangential to the L5 vertebra posterior wall that intersects the S1 vertebra endplate. The lumbosacral angle (LSA) was also measured to assess the orientation of L5 over S1. The slip percentage and grade obtained from the 2 techniques were compared. The influence of the LSA on the measurement of slip severity was also assessed. RESULTS A significant difference (P < 10(-5)) was found between technique 1 (mean = 34.2% +/- 32.6%) and technique 2 (mean = 42.5% +/- 25.8%) with respect to the slip percentage. Eight subjects were found to switch classification from a low to a high-grade slip (or inversely) depending on the technique used. There was a significant relationship between the LSA and the difference in the measurement of slip percentage using either technique 1 or technique 2. CONCLUSION The 2 measurement techniques can have a significant impact on the interpretation of slip severity in spondylolisthesis. The differences between the measurement techniques are influenced by the orientation of L5 over S1 and could potentially affect the clinical decision making. It is important to standardize and specify the technique used to plan and assess interventions in L5-S1 developmental spondylolisthesis.
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Abstract
STUDY DESIGN A radiographic study was conducted to investigate the accuracy of computer-assisted measurement of sacral morphology in a population with developmental L5-S1 spondylolisthesis. OBJECTIVE The purpose of this study was to evaluate the inter- and intraobserver variability of computer measurements of sacral morphology. SUMMARY AND BACKGROUND DATA Recent studies have shown differences in sacral morphology among patients with spondylolisthesis. The sacral table angle (STA) is a fundamental sacral anatomic parameter that is specific and constant to each individual, while the S1 superior and S2 inferior angles are defined as anatomic measures specific to S1 and S2. Sacral kyphosis measured by Ferguson or Cobb method has also been used to evaluate the sagittal shape of the sacrum. Currently, computerized measures are gaining popularity for the study of sagittal balance, but their reliability especially in sacral morphology has never been properly evaluated. METHODS The standing lateral radiographs of 30 adolescents were randomly selected from the radiographic database of our institution: 10 radiographs of asymptomatic individuals, 10 of subjects with low grade L5-S1 spondylolisthesis and 10 with high grade L5-S1 developmental spondylolisthesis. Three surgeons measured sacral morphologic variables on the 30 radiographs at 2 occasions, with a 15 days interval between the 2 sessions, using a computer assisted technique. Intraclass correlation coefficients (ICCs) were used for statistical analysis. RESULTS The ICC values measured within observers varied between 0.951 to 0.995, whereas the ICC measured between observers varied between 0.957 to 0.995. There was a slight decrease of the ICC measured in the high grade L5-S1 spondylolisthesis group compared to the normal subjects. However, the difference was not statistically significant. CONCLUSION These results confirm the reliability and repeatability of computer-assisted angular measurement of sacral morphology in subjects with L5-S1 spondylolisthesis, even in the presence of lumbosacral junction dysplasia. The use of computerized measurements can be recommended for the evaluation of the sagittal sacral anatomy in future clinical and research studies.
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Differences in male and female spino-pelvic alignment in asymptomatic young adults: a three-dimensional analysis using upright low-dose digital biplanar X-rays. Spine (Phila Pa 1976) 2009; 34:E826-32. [PMID: 19927088 DOI: 10.1097/brs.0b013e3181a9fd85] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A three-dimensional analysis of spino-pelvic alignment in 60 asymptomatic young adult males and females. OBJECTIVES To analyze the differences in sagittal spino-pelvic alignment in a group of asymptomatic young adult males and females and describe gender specific reference values. SUMMARY OF BACKGROUND DATA Several spinal disorders like idiopathic scoliosis and Scheuermann's disease have a well-known sex-related prevalence ratio. As spino-pelvic alignment plays an important role in spinal biomechanics, it is imperative to analyze possible differences between the male and female spino-pelvic alignment. Furthermore, in spinal fusion surgery, normal sagittal balance should be recreated as closely as possible. METHODS An innovative biplanar ultra low-dose radiographic technique was used to obtain three-dimensional reconstructions of the spine (T1-L5), sacrum, and pelvis in a freestanding position of 30 asymptomatic young male and 30 young female adults. Values were calculated for thoracic kyphosis (T4-T12), lumbar lordosis (L1-S1), total and regional lumbopelvic lordosis (PRT12, PRL2, PRL4, and PRL5), sagittal plumb line of T1, T4, and T9 (HAT1, HAT4, and HAT9), T1-L5 sagittal spinal inclination, T9 sagittal offset, and pelvic parameters (pelvic tilt, sacral slope, and pelvic incidence). In addition, vertebral inclination in the sagittal plane of each vertebra was measured. Differences in spino-pelvic alignment between the sexes were analyzed. RESULTS The female spine was more dorsally inclined (11 degrees vs. 8 degrees ; P = 0.003). High thoracic and thoracolumbar vertebrae were more dorsally inclined in women than in men. Thoracic kyphosis, lumbar lordosis, regional lumbopelvic lordosis, sagittal plumb lines, T9 sagittal offset, and pelvic parameters were not statistically different between the sexes. CONCLUSION These results indicate that the female spine is definitely different from the male spine. The spine as whole and individual vertebrae in certain regions of the normal spine is more backwardly inclined in females than in males. Based on our previous research this signifies that these spinal regions are subjected to different biomechanical loading conditions. These vertebral segments are possibly less rotationally stable in females than in males.
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Classification of pelvic and spinal postural patterns in upright position. Specific cases of scoliotic patients. Comput Med Imaging Graph 2009; 33:634-43. [PMID: 19635659 DOI: 10.1016/j.compmedimag.2009.06.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Revised: 06/25/2009] [Accepted: 06/30/2009] [Indexed: 11/22/2022]
Abstract
The 3D analyses of spinal shapes and postural features give a great number of data. The global patient posture includes his pelvic morphology and tilting, and his pelvic and spinal balance. In some scoliotic spines, the spinal curve belongs to a unique plane. In other scoliotic patients, the spinal curve shows several plane regions. The spinal structures are modeled from parameters locating the structural planes and by values of maximum curvatures. Some parameters have been introduced for describing the postural patterns and the spinal deformities. For each tested patient, each major parameter has been characterized by an index of class.
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Postural model of sagittal spino-pelvic alignment and its relevance for lumbosacral developmental spondylolisthesis. Spine (Phila Pa 1976) 2008; 33:2316-25. [PMID: 18827698 DOI: 10.1097/brs.0b013e318186b236] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Comparative study of sagittal spino-pelvic alignment in children and adolescents with developmental lumbosacral spondylolisthesis compared with asymptomatic subjects. OBJECTIVE To develop a global postural model of sagittal spino-pelvic alignment. SUMMARY OF BACKGROUND DATA The relationships between parameters of sagittal spino-pelvic alignment in developmental spondylolisthesis are still unclear. METHODS Radiographs of 120 control subjects and 131 subjects with developmental spondylolisthesis (91 low-grade, 40 high-grade) were reviewed. Subjects with high-grade spondylolisthesis were divided according to their sacro-pelvic alignment: balanced versus retroverted sacro-pelvis. Parameters of the sacro-pelvis (pelvic incidence, pelvic tilt, sacral slope), lumbosacral region (lumbosacral angle, slip percentage), lumbar spine (lumbar lordosis, lumbar tilt), thoracic spine (thoracic kyphosis, thoracic tilt), and global balance (spinal tilt, sagittal offset between C7 and femoral heads) were assessed. Parameters were compared between all groups and a correlation study was performed between all parameters. A postural model that includes the measured parameters was used to analyze the obtained correlations. RESULTS Significant differences in all parameters are found between all groups, except for sagittal offset. The pattern and strength of correlations is similar between normal and low-grade subjects, showing interdependence between sacro-pelvic, lumbosacral, lumbar, and thoracic regions. The pattern of relationships was altered in high-grade spondylolisthesis, especially for subjects with a retroverted sacro-pelvis for which correlations between pelvic incidence and pelvic tilt, and between the sacro-pelvic unit and lumbar spine geometry are lost. CONCLUSION Children and adolescents stand with a relatively constant global sagittal spino-pelvic alignment, regardless of the local lumbosacral deformity. A normal posture is maintained in low-grade spondylolisthesis and in high-grade spondylolisthesis with a balanced sacro-pelvis. Posture is abnormal in high-grade spondylolisthesis associated with a retroverted sacro-pelvis, suggesting that surgical reduction of the local lumbosacral deformity in these patients could be attempted to restore a normal posture.
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Abstract
STUDY DESIGN A radiographic study was conducted to investigate sacral morphology in a children and adolescent population with developmental L5-S1 spondylolisthesis. OBJECTIVE To determine the relationship between sacral morphology and developmental L5-S1 spondylolisthesis. SUMMARY AND BACKGROUND DATA The morphology of the adult sacrum has been recently shown to be abnormal in low grade spondylolisthesis. However, sacral morphology has never been evaluated in a pediatric population where remodeling and secondary changes are less pronounced. It remains unknown if these changes in sacral morphology are primary or secondary in developmental L5-S1 spondylolisthesis. METHODS The lateral standing radiographs of 131 subjects, aged 6 to 20 years old with developmental L5-S1 spondylolisthesis (91 low grade and 40 high grade) were analyzed with a dedicated software allowing to measure the following parameters, which were analyzed for each subject by the same individual and compared to a cohort of 120 subjects without any spinal pathology with similar age and sex distribution: the sacral table index (STI), sacral table angle (STA), sacral kyphosis (SK), S1 superior angle, S2 inferior angle, and grade of spondylolisthesis. Student t test was used to compare the parameters between the groups. RESULTS This study demonstrated that STA is significantly smaller (P < 0.01) in children and adolescents with L5-S1 spondylolisthesis compared to a similar control group. Furthermore, STA is significantly smaller in high-grade spondylolisthesis when compared to subjects with low grade. There is also a significant difference in segmental sacral morphology (S1 and S2 anatomy) in the spondylolisthesis group. Increasing sacral kyphosis is also found to be significantly associated with spondylolisthesis. CONCLUSION The sagittal sacral morphology is a constant anatomic variable specific to each individual and unaffected by the position of the patient in space. The anatomy of the sacrum in children and adolescents with L5-S1 spondylolisthesis is particular and different from a control group. This study suggests that sacral anatomy may have a direct influence on the progression of spondylolisthesis; a lower STA and higher sacral kyphosis may be 2 factors predisposing to vertebral slip in developmental spondylolisthesis.
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Intra- and inter-observer reliability of determining radiographic sagittal parameters of the spine and pelvis using a manual and a computer-assisted methods. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2008; 17:1373-9. [PMID: 18726124 DOI: 10.1007/s00586-008-0755-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2008] [Revised: 05/22/2008] [Accepted: 08/10/2008] [Indexed: 10/21/2022]
Abstract
Sagittal imbalance is a significant factor in determining clinical treatment outcomes in patients with deformity. Measurement of sagittal alignment using the traditional Cobb technique is frequently hampered by difficulty in visualizing landmarks. This report compares traditional manual measurement techniques to a computer-assisted sagittal plane measurement program which uses a radius arc methodology. The intra and inter-observer reliability of the computer program has been shown to be 0.92-0.99. Twenty-nine lateral 90 cm radiographs were measured by a computer program for an array of sagittal plane measurements. Ten experienced orthopedic spine surgeons manually measured the same parameters twice, at least 48 h apart, using a digital caliper and a standardized radiographic manual. Intraclass correlations were used to determine intra- and interobserver reliability between different manual measures and between manual measures and computer assisted-measures. The inter-observer reliability between manual measures was poor, ranging from -0.02 to 0.64 for the different sagittal measures. The intra-observer reliability in manual measures was better ranging from 0.40 to 0.93. Comparing manual to computer-assisted measures, the ICC ranged from 0.07 to 0.75. Surgeons agreed more often with each other than with the machine when measuring the lumbar curve, the thoracic curve, and the spino-sacral angle. The reliability of the computer program is significantly higher for all measures except for lumbar lordosis. A computer-assisted program produces a reliable measurement of the sagittal profile of the spine by eliminating the need for distinctly visible endplates. The use of a radial arc methodology allows for infinite data points to be used along the spine to determine sagittal measurements. The integration of this technique with digital radiography's ability to adjust image contrast and brightness will enable the superior identification of key anatomical parameters normally not available for measurement on traditional radiographs, improving the consistency of sagittal measurement.
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Morphologic parameters of sacropelvic anatomy affecting spinal pathology. CURRENT ORTHOPAEDIC PRACTICE 2008. [DOI: 10.1097/bco.0b013e3282f79b69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Labelle H, Roussouly P, Chopin D, Berthonnaud E, Hresko T, O'Brien M. Spino-pelvic alignment after surgical correction for developmental spondylolisthesis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2008; 17:1170-6. [PMID: 18600350 DOI: 10.1007/s00586-008-0713-y] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2008] [Revised: 03/23/2008] [Accepted: 06/18/2008] [Indexed: 10/21/2022]
Abstract
This study is a retrospective multi-centre analysis of changes in spino-pelvic sagittal alignment after surgical correction of L5-S1 developmental spondylolisthesis. The purpose of this study was to determine how sagittal spino-pelvic alignment is affected by surgery, with the hypothesis that surgical correction at the lumbo-sacral level is associated with an improvement in the shape of the spine and in the orientation of the pelvis. Whether L5-S1 high grade spondylolisthesis should or should not be reduced remains a controversial subject. A popular method of treatment has been in situ fusion, but studies have reported a high rate of pseudarthrosis, slip progression and persistent cosmetic deformity. Spinal instrumentation with pedicle screws has generated a renewed interest for reduction, but the indications for this treatment and its effect on spino-pelvic alignment remain poorly defined. Recent evidence indicates that reduction might be indicated for subjects with an unbalanced (retroverted or vertical) pelvis. This is a retrospective multi-centre analysis of 73 subjects (mean age 18 +/- 3 years) with developmental spondylolisthesis and an average follow-up of 1.9 years after reduction and posterior fusion with spinal instrumentation or cast immobilisation. Spinal and pelvic alignment were measured on standing lateral digitised X-rays using a computer software allowing a very high inter and intra observer reliability. Pelvic incidence was unaffected by surgery. The most important changes were noted for grade, L5 Incidence, lumbo-sacral-angle, and lumbar lordosis, which all decreased significantly towards normal adult values. At first evaluation, pelvic tilt, sacral slope and thoracic kyphosis appeared minimally affected by surgery. However, after classifying subjects into balanced and unbalanced pelvis, significant improvements were noted in pelvic alignment in both the sub-groups, with 40% of cases switching groups, the majority from an unbalanced to a balanced pelvis alignment. The direction and magnitude of these changes were significantly different by sub-group: sacral slope decreased in the balanced pelvis group but increased in the unbalanced group, while pelvic tilt values did the opposite. While pelvic shape is unaffected by attempts at surgical reduction, proper repositioning of L5 over S1 significantly improves pelvic balance and lumbar shape by decreasing the abnormally high lumbar lordosis and abnormal pelvic retroversion. These results emphasise the importance of sub-dividing subjects with high grade developmental spondylolisthesis into unbalanced and balanced pelvis groups, and further support the contention that reduction techniques might be considered for the unbalanced retroverted pelvis sub-group.
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Affiliation(s)
- Hubert Labelle
- Division of Orthopaedics, Sainte-Justine University Center Hospital, 3175 Côte Sainte-Catherine Rd, Montreal, QC H3T 1C5, Canada.
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Hresko MT, Labelle H, Roussouly P, Berthonnaud E. Classification of high-grade spondylolistheses based on pelvic version and spine balance: possible rationale for reduction. Spine (Phila Pa 1976) 2007; 32:2208-13. [PMID: 17873812 DOI: 10.1097/brs.0b013e31814b2cee] [Citation(s) in RCA: 125] [Impact Index Per Article: 7.4] [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 review of a radiographic database of high-grade spondylolisthesis patients in comparison with asymptomatic controls. OBJECTIVE To analyze the sagittal spinopelvic alignment in high-grade spondylolisthesis patients and identify subgroups that may require reduction to restore sagittal balance. SUMMARY OF BACKGROUND DATA High-grade spondylolisthesis is associated with an abnormally high pelvic incidence (PI); however, the spatial orientation of the pelvis, determined by sacral slope (SS) and pelvic tilt (PT), is not known. We hypothesized that sagittal spinal alignment would vary with the pelvic orientation. METHODS Digitized sagittal radiographs of 133 high-grade spondylolisthesis patients (mean age, 17 years) were measured to determined sagittal alignment. K-means cluster analysis identified 2 groups based on the PT and SS, which were compared by paired t test. Comparisons were made to asymptomatic controls matched for PI. RESULTS High-grade spondylolisthesis patients had a mean PI of 78.9 degrees +/- 12.1 degrees . Cluster analysis identified a retroverted, unbalanced pelvis group with high PT (36.5 degrees +/- 8.0 degrees )/low SS (40.3 degrees +/- 9.0 degrees ) and a balanced pelvic group with low PT (mean 21.3 degrees +/- 8.2 degrees )/high SS (59.9 degrees +/- 11.2 degrees ). The retroverted pelvis group had significantly greater L5 incidence and lumbosacral angle with less thoracic kyphosis than the balanced pelvic group. A total of 83% of controls had a "balanced pelvis" based on the categorization by SS and PT. CONCLUSION Analysis of sagittal alignment of high-grade spondylolisthesis patients revealed distinct groups termed "balanced" and "unbalanced" pelvis. The PT and SS were similar in controls and balanced pelvis patients. Unbalanced pelvis patients had a sagittal spinal alignment that differed from the balanced pelvis and control groups. Treatment strategies for high-grade spondylolisthesis should reflect the different mechanical strain on the spinopelvic junction in each group; reduction techniques might be considered in patients with an unbalanced pelvis high-grade spondylolisthesis.
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Affiliation(s)
- Michael T Hresko
- Department of Orthopaedic Surgery, Children Hospital Boston, Harvard Medical School, Boston, MA 02115, USA.
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Pinel-Giroux FM, Mac-Thiong JM, de Guise JA, Berthonnaud E, Labelle H. Computerized assessment of sagittal curvatures of the spine: comparison between Cobb and tangent circles techniques. ACTA ACUST UNITED AC 2006; 19:507-12. [PMID: 17021415 DOI: 10.1097/01.bsd.0000211206.15997.dd] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The tangent circles technique has been proposed as an alternative to the Cobb angle technique to assess sagittal curves of the spine. However, it has never been compared directly to the Cobb technique. This study compares the reproducibility and clinical relevance of the maximum Cobb angle and tangent circles techniques. METHOD Standing sagittal radiographs of the spine of 10 adolescents with idiopathic scoliosis, 10 adolescents with spondylolisthesis, and 10 healthy adolescents were used. Thoracic kyphosis (TK) and lumbar lordosis (LL) were measured by 3 observers using the maximum Cobb angle and the tangent circles techniques. Intra- and interobserver intraclass correlation coefficients (ICCs) were calculated. RESULT Intra- and interobserver ICCs for TK were 0.88 and 0.85, respectively, for the maximum Cobb angle technique, and 0.94 and 0.83, respectively, for the tangent circles technique. Intra- and interobserver ICCs for LL were 0.97 and 0.77, respectively, for the maximum Cobb angle technique, and 0.88 and 0.94, respectively, for the tangent circles technique. The 2 techniques were highly correlated for the measurement of the TK (r=0.93) and LL (r=0.88). CONCLUSION Both techniques provide excellent intra- and interobserver reproducibility. Tangent circles technique may be a good alternative to the Cobb angle technique because it allows the evaluation of the global geometry of sagittal spinal curves, especially when there is limited visibility of bony structures on radiographs.
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Roussouly P, Gollogly S, Berthonnaud E, Labelle H, Weidenbaum M. Sagittal alignment of the spine and pelvis in the presence of L5-s1 isthmic lysis and low-grade spondylolisthesis. Spine (Phila Pa 1976) 2006; 31:2484-90. [PMID: 17023859 DOI: 10.1097/01.brs.0000239155.37261.69] [Citation(s) in RCA: 142] [Impact Index Per Article: 7.9] [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 study of 82 patients with L5-S1 spondylolysis or spondylolisthesis of less than 50% displacement of L5 on S1. OBJECTIVE To measure and describe the sagittal alignment of the spine and pelvis in patients with spondylolysis before the development of a large secondary deformity associated with progression of the spondylolisthesis. SUMMARY OF BACKGROUND DATA Several publications have addressed the alignment of the spine and pelvis as an important factor in the occurrence, symptomatology, progression, and treatment of spondylolysis and spondylolisthesis. To our knowledge, this is the first report to systematically document the native sagittal alignment of affected patients and compare them to a large control population. MATERIALS AND METHODS The sagittal alignment in this cohort of 82 patients was compared with a control population of 160 patients without symptoms of back pain or radiographic abnormalities of the spine and pelvis that was the subject of a previous study. RESULTS Patients with spondylolysis and low-grade spondylolisthesis demonstrate increased pelvic incidence, increased lumbar lordosis, but less segmental extension between L5 and S1 than in a normal population. CONCLUSIONS These data suggest that differences in the sagittal alignment of the spine and pelvis may influence the biomechanical environment that results in the development of spondylolysis and progressive spondylolisthesis.
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Affiliation(s)
- Pierre Roussouly
- Department of Orthopedic Surgery, Centre Des Massues, Lyon, France
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