Skip to main content

Advertisement

SpringerLink
Log in

Characteristics and treatment of dynamic sagittal imbalance in adult spinal deformity

  • Original Article
  • Published:
European Spine Journal Aims and scope Submit manuscript

Abstract

Objective

To raise the diagnostic criteria, classification and treatment strategy of dynamic sagittal imbalance (DSI).

Methods

One hundred thirty-three adult spinal deformity (ASD) patients with stooping and back pain after walking were retrospectively analyzed. Based on the radiographic parameters and Oswestry Disability Index (ODI) scores, the diagnostic criteria of DSI were raised. DSI patients received nonoperative treatment and (or) surgery. Radiographic parameters and health-related quality of life (HRQOL) outcomes would be measured and compared between prewalk and postwalk and among each subgroup.

Results

One hundred thirty-three ASD patients with stooping and back pain after walking were enrolled in our study. The quantitative diagnostic criteria was prewalk SVA < 40 mm and postwalk SVA-prewalk SVA ≥ 20 mm after 10-min walk. Based on the quantitative diagnostic criteria of DSI raised by our team, DSI patients could be classified into three groups: 20 mm ≤ ΔSVA < 60 mm (mild, 31.0%), 60 mm ≤ ΔSVA < 100 mm (moderate, 42.1%) and ΔSVA ≥ 100 mm (severe, 27.0%). After nonoperative treatment, the ΔSVA in mild and moderate group was prominently decreased (P < 0.001) with the significant improvement of HRQOL outcomes (P < 0.001), while there was no significant change in ΔSVA and clinical outcomes in group C (P > 0.05). Patients who received the operative treatment showed prominent improvement in ΔSVA and clinical outcomes (P < 0.001).

Conclusion

Our study proposed a quantitative diagnostic criteria and novel classification of DSI. Nonoperative treatment is effective for most DSI patients with ΔSVA < 100 mm, while the majority of DSI patients with ΔSVA ≥ 100 mm need operative intervention.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8

Similar content being viewed by others

References

  1. Bailey JF, Matthew RP, Seko S, Curran P, Chu L, Berven SH, Deviren V, Burch S, Lotz JC (2019) ISSLS PRIZE IN BIOENGINEERING SCIENCE 2019: biomechanical changes in dynamic sagittal balance and lower limb compensatory strategies following realignment surgery in adult spinal deformity patients. Eur Spine J 28:905–913. https://doi.org/10.1007/s00586-019-05925-2

    Article  PubMed  PubMed Central  Google Scholar 

  2. Diebo BG, Shah NV, Boachie-Adjei O, Zhu F, Rothenfluh DA, Paulino CB, Schwab FJ, Lafage V (2019) Adult spinal deformity. Lancet 394:160–172. https://doi.org/10.1016/S0140-6736(19)31125-0

    Article  PubMed  Google Scholar 

  3. Youssef JA, Orndorff DO, Patty CA, Scott MA, Price HL, Hamlin LF, Williams TL, Uribe JS, Deviren V (2013) Current status of adult spinal deformity. Global Spine J 3:51–62. https://doi.org/10.1055/s-0032-1326950

    Article  CAS  PubMed  Google Scholar 

  4. Ploumis A, Simpson AK, Cha TD, Herzog JP, Wood KB (2015) Coronal spinal balance in adult spine deformity patients with long spinal fusions: a minimum 2- to 5-year follow-up study. J Spinal Disord Tech 28:341–347. https://doi.org/10.1097/BSD.0b013e3182aab2ff

    Article  PubMed  Google Scholar 

  5. Ailon T, Smith JS, Shaffrey CI, Lenke LG, Brodke D, Harrop JS, Fehlings M, Ames CP (2015) Degenerative spinal deformity. Neurosurgery 77(Suppl 4):S75–91. https://doi.org/10.1227/NEU.0000000000000938

    Article  PubMed  Google Scholar 

  6. Angevine PD, Bray D, Cloney M, Malone H (2019) Uncertainty in the relationship between sagittal alignment and patient-reported outcomes. Neurosurgery. https://doi.org/10.1093/neuros/nyz228

    Article  Google Scholar 

  7. McDowell MM, Tempel ZJ, Gandhoke GS, Khattar NK, Hamilton DK, Kanter AS, Okonkwo DO (2017) Evolution of sagittal imbalance following corrective surgery for sagittal plane deformity. Neurosurgery 81:129–134. https://doi.org/10.1093/neuros/nyx145

    Article  PubMed  Google Scholar 

  8. Katsu M, Ohba T, Ebata S, Oba H, Koyama K, Haro H (2019) Potential role of paraspinal musculature in the maintenance of spinopelvic alignment in patients with adult spinal deformities. Clin Spine Surg. https://doi.org/10.1097/BSD.0000000000000862

    Article  Google Scholar 

  9. Yagi M, Hosogane N, Watanabe K, Asazuma T, Matsumoto M, Keio Spine Research G (2016) The paravertebral muscle and psoas for the maintenance of global spinal alignment in patient with degenerative lumbar scoliosis. Spine J 16:451–458. https://doi.org/10.1016/j.spinee.2015.07.001

    Article  Google Scholar 

  10. Bess S, Schwab F, Lafage V, Shaffrey CI, Ames CP (2013) Classifications for adult spinal deformity and use of the Scoliosis Research Society-Schwab Adult Spinal Deformity Classification. Neurosurg Clin N Am 24:185–193. https://doi.org/10.1016/j.nec.2012.12.008

    Article  PubMed  Google Scholar 

  11. Shiba Y, Taneichi H, Inami S, Moridaira H, Takeuchi D, Nohara Y (2016) Dynamic global sagittal alignment evaluated by three-dimensional gait analysis in patients with degenerative lumbar kyphoscoliosis. Eur Spine J 25:2572–2579. https://doi.org/10.1007/s00586-016-4648-4

    Article  PubMed  Google Scholar 

  12. Lee CS, Lee CK, Kim YT, Hong YM, Yoo JH (2001) Dynamic sagittal imbalance of the spine in degenerative flat back: significance of pelvic tilt in surgical treatment. Spine (Phila Pa 1976) 26:2029–2035. https://doi.org/10.1097/00007632-200109150-00017

    Article  CAS  Google Scholar 

  13. Bae J, Theologis AA, Jang JS, Lee SH, Deviren V (2017) Impact of fatigue on maintenance of upright posture: dynamic assessment of sagittal spinal deformity parameters after walking 10 minutes. Spine (Phila Pa 1976) 42:733–739. https://doi.org/10.1097/BRS.0000000000001898

    Article  Google Scholar 

  14. Smith JS, Lafage V, Shaffrey CI, Schwab F, Lafage R, Hostin R, O'Brien M, Boachie-Adjei O, Akbarnia BA, Mundis GM, Errico T, Kim HJ, Protopsaltis TS, Hamilton DK, Scheer JK, Sciubba D, Ailon T, Fu KM, Kelly MP, Zebala L, Line B, Klineberg E, Gupta M, Deviren V, Hart R, Burton D, Bess S, Ames CP, International Spine Study G (2016) Outcomes of operative and nonoperative treatment for adult spinal deformity: a prospective, multicenter, propensity-matched cohort assessment with minimum 2-year follow-up. Neurosurgery 78:851–861. https://doi.org/10.1227/NEU.0000000000001116

    Article  Google Scholar 

  15. Arima H, Yamato Y, Hasegawa T, Kobayashi S, Yoshida G, Yasuda T, Banno T, Oe S, Mihara Y, Togawa D, Matsuyama Y (2017) Extensive corrective fixation surgeries for adult spinal deformity improve posture and lower extremity kinematics during gait. Spine (Phila Pa 1976) 42:1456–1463

    Article  Google Scholar 

  16. Engsberg JR, Bridwell KH, Wagner JM, Uhrich ML, Blanke K, Lenke LG (2003) Gait changes as the result of deformity reconstruction surgery in a group of adults with lumbar scoliosis. Spine (Phila Pa 1976) 28:1836–1843. https://doi.org/10.1097/00007632-200308150-00012 (discussion 1844)

    Article  Google Scholar 

  17. Slobodyanyuk K, Poorman CE, Smith JS, Protopsaltis TS, Hostin R, Bess S, Mundis GM, Jr., Schwab FJ, Lafage V, International Spine Study G (2014) Clinical improvement through nonoperative treatment of adult spinal deformity: who is likely to benefit? Neurosurg Focus 36:E2. https://doi.org/10.3171/2014.3.FOCUS1426

    Article  Google Scholar 

  18. Acaroglu E, Yavuz AC, Guler UO, Yuksel S, Yavuz Y, Domingo-Sabat M, Pellise F, Alanay A, Perez Grueso FS, Kleinstuck F, Obeid I, European Spine Study G (2016) A decision analysis to identify the ideal treatment for adult spinal deformity: is surgery better than non-surgical treatment in improving health-related quality of life and decreasing the disease burden? Eur Spine J 25:2390–2400. https://doi.org/10.1007/s00586-016-4413-8

    Article  Google Scholar 

  19. Tonosu J, Takeshita K, Hara N, Matsudaira K, Kato S, Masuda K, Chikuda H (2012) The normative score and the cut-off value of the oswestry disability index (ODI). Eur Spine J 21:1596–1602. https://doi.org/10.1007/s00586-012-2173-7

    Article  PubMed  PubMed Central  Google Scholar 

  20. Moal B, Lafage V, Smith JS, Ames CP, Mundis G, Terran JS, Klineberg E, Hart R, Boachie-Adjei O, Bess S, Skalli W, Schwab F, International Spine Study G (2015) Clinical improvement through surgery for adult spinal deformity: what can be expected and who is likely to benefit most? Spine Deform 3:566–574. https://doi.org/10.1016/j.jspd.2015.04.004

    Article  Google Scholar 

  21. Parker SL, Mendenhall SK, Shau D, Adogwa O, Cheng JS, Anderson WN, Devin CJ, McGirt MJ (2012) Determination of minimum clinically important difference in pain, disability, and quality of life after extension of fusion for adjacent-segment disease. J Neurosurg Spine 16:61–67. https://doi.org/10.3171/2011.8.SPINE1194

    Article  PubMed  Google Scholar 

  22. Lafage V, Schwab F, Patel A, Hawkinson N, Farcy JP (2009) Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity. Spine (Phila Pa 1976) 34:E599–606. https://doi.org/10.1097/BRS.0b013e3181aad219

    Article  Google Scholar 

  23. Schwab F, Farcy JP, Bridwell K, Berven S, Glassman S, Harrast J, Horton W (2006) A clinical impact classification of scoliosis in the adult. Spine (Phila Pa 1976) 31:2109–2114. https://doi.org/10.1097/01.brs.0000231725.38943.ab

    Article  Google Scholar 

  24. Schwab F, Patel A, Ungar B, Farcy JP, Lafage V (2010) Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery. Spine (Phila Pa 1976) 35:2224–2231. https://doi.org/10.1097/BRS.0b013e3181ee6bd4

    Article  Google Scholar 

  25. Barrey C, Roussouly P, Le Huec JC, D'Acunzi G, Perrin G (2013) Compensatory mechanisms contributing to keep the sagittal balance of the spine. Eur Spine J 22(Suppl 6):S834–841. https://doi.org/10.1007/s00586-013-3030-z

    Article  PubMed  Google Scholar 

  26. Diebo BG, Varghese JJ, Lafage R, Schwab FJ, Lafage V (2015) Sagittal alignment of the spine: What do you need to know? Clin Neurol Neurosurg 139:295–301. https://doi.org/10.1016/j.clineuro.2015.10.024

    Article  PubMed  Google Scholar 

  27. Shahidi B, Parra CL, Berry DB, Hubbard JC, Gombatto S, Zlomislic V, Allen RT, Hughes-Austin J, Garfin S, Ward SR (2017) Contribution of lumbar spine pathology and age to paraspinal muscle size and fatty infiltration. Spine (Phila Pa 1976) 42:616–623. https://doi.org/10.1097/BRS.0000000000001848

    Article  Google Scholar 

  28. Banno T, Yamato Y, Hasegawa T, Kobayashi S, Togawa D, Oe S, Mihara Y, Kurosu K, Yamamoto N, Matsuyama Y (2017) Assessment of the cross-sectional areas of the psoas major and multifidus muscles in patients with adult spinal deformity: a case-control study. Clin Spine Surg 30:E968–E973. https://doi.org/10.1097/BSD.0000000000000480

    Article  PubMed  Google Scholar 

  29. Jun HS, Kim JH, Ahn JH, Chang IB, Song JH, Kim TH, Park MS, Chan Kim Y, Kim SW, Oh JK, Yoon DH (2016) The effect of lumbar spinal muscle on spinal sagittal alignment: evaluating muscle quantity and quality. Neurosurgery 79:847–855. https://doi.org/10.1227/NEU.0000000000001269

    Article  PubMed  Google Scholar 

  30. Banno T, Arima H, Hasegawa T, Yamato Y, Togawa D, Yoshida G, Yasuda T, Oe S, Mihara Y, Ushirozako H, Matsuyama Y (2019) The effect of paravertebral muscle on the maintenance of upright posture in patients with adult spinal deformity. Spine Deform 7:125–131. https://doi.org/10.1016/j.jspd.2018.06.008

    Article  PubMed  Google Scholar 

  31. Shafaq N, Suzuki A, Matsumura A, Terai H, Toyoda H, Yasuda H, Ibrahim M, Nakamura H (2012) Asymmetric degeneration of paravertebral muscles in patients with degenerative lumbar scoliosis. Spine (Phila Pa 1976) 37:1398–1406. https://doi.org/10.1097/BRS.0b013e31824c767e

    Article  Google Scholar 

  32. Yagi M, Kaneko S, Yato Y, Asazuma T, Machida M (2016) Walking sagittal balance correction by pedicle subtraction osteotomy in adults with fixed sagittal imbalance. Eur Spine J 25:2488–2496. https://doi.org/10.1007/s00586-016-4604-3

    Article  PubMed  Google Scholar 

Download references

Funding

This research has not received any funding.

Author information

Author notes

  1. Jia Yin, Xiao Ma and Tao Lin have contributed equally to this work.

Authors and Affiliations

  1. Department of Orthopedics, Changzheng Hospital, Second Affiliated Hospital of Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People’s Republic of China

    Jia Yin, Xiao Ma, Tao Lin, Rui Gao & Xuhui Zhou

Authors
  1. Jia Yin
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Xiao Ma
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Tao Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Rui Gao
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Xuhui Zhou
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding authors

Correspondence to Rui Gao or Xuhui Zhou.

Ethics declarations

Conflict of interest

All authors declared that they have no potential conflict of interest.

Ethical approval

The research project was approved by the ethics department of Shanghai Changzheng Hospital, Shanghai. We have consensus with all participants. All the procedures were done under the Declaration of Helsinki and relevant policies in China. The Manuscript submitted does not contain information about medical device(s)/drug(s).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Yin, J., Ma, X., Lin, T. et al. Characteristics and treatment of dynamic sagittal imbalance in adult spinal deformity. Eur Spine J 29, 2340–2353 (2020). https://doi.org/10.1007/s00586-020-06459-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-020-06459-8

Keywords

Search

Navigation