European Spine Journal

, Volume 23, Supplement 6, pp 616–627 | Cite as

Pelvic parameters and global spine balance for spine degenerative disease: the importance of containing for the well being of content

  • Diego Garbossa
  • Matteo Pejrona
  • Marco Damilano
  • Valerio Sansone
  • Alessandro Ducati
  • Pedro Berjano
Original Article



Spinal deformities and pathologies of the spinopelvic junction are conditions affecting up to 60–70 % of the general aging population. In this review, we discuss the more recent knowledge on sagittal balance and its clinical implications.


Review of the literature regarding global spine balance.


Global spinal balance and its relationship to the pelvis correlate closely with disability and quality of life. It has been demonstrated that extensive surgery, previously considered to have poor balance between risks and outcomes, causes great improvements in health-related quality of life in the oldest age groups.


Failure to restore normal sagittal alignment in patients primarily operated for other than deformity results in unacceptable rates of poor results and revision surgery.


Sagittal balance Review Deformities Scoliosis Pelvic Compensatory Spino-femoral angle 


Conflict of interest



  1. 1.
    Aebi M (2005) The adult scoliosis. Eur Spine J 14(10):925–948PubMedCrossRefGoogle Scholar
  2. 2.
    Bernhardt M, Bridwell KH (1989) Segmental analysis of the sagittal plane alignment of the normal thoracic and lumbar spines and thoracolumbar junction. Spine 14:717–721PubMedCrossRefGoogle Scholar
  3. 3.
    Berven SH, Deviren V, Smith JA, Hu SH, Bradford DS (2003) Management of fixed sagittal plane deformity: outcome of combined anterior and posterior surgery. Spine 28(15):1710–1715PubMedGoogle Scholar
  4. 4.
    Booth KC, Bridwell KH, Lenke LG, Baldus CR, Blanke KM (1999) Complications and predictive factors for the successful treatment of flatback deformity (fixed sagittal imbalance). Spine 24(16):1712–1720PubMedCrossRefGoogle Scholar
  5. 5.
    Boulay C, Tardieu C, Hecquet J, Benaim C, Mouilleseaux B, Marty C, Prat-Pradal D, Legaye J, Duval-Beaupère G, Pélissier J (2006) Sagittal alignment of spine and pelvis regulated by pelvic incidence: standard values and prediction of lordosis. Eur Spine J 15:415–422PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Bourghli A, Guérin P, Vital JM, Aurouer N, Luc S, Gille O, Pointillart V, Obeid I (2012) Posterior spinal fusion from T2 to the sacrum for the management of major deformities in patients with Parkinson disease: a retrospective review with analysis of complications. J Spinal Disord Tech 25(3):53–60CrossRefGoogle Scholar
  7. 7.
    Bridwell KH, Lewis SJ, Lenke LG, Baldus C, Blanke K (2003) Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance. J Bone Joint Surg Am 85(3):454–463PubMedGoogle Scholar
  8. 8.
    Cho KJ, Bridwell KH, Lenke LG, Berra A, Baldus C (2005) Comparison of Smith-Petersen versus pedicle subtraction osteotomy for the correction of fixed sagittal imbalance. Spine 30(18):2030–2037PubMedCrossRefGoogle Scholar
  9. 9.
    Cho KJ, Lenke LG, Bridwell KH, Kamiya M, Sides B (2009) Selection of the optimal distal fusion level in posterior instrumentation and fusion for thoracic hyperkyphosis: the sagittal stable vertebra concept. Spine 34:765–770PubMedCrossRefGoogle Scholar
  10. 10.
    Finocchiaro FM, Nena U, Lo Scalzo V, Monterumici DA (2012) Treatment of kyphotic deformities in adults: our experience. Eur Spine J 21(1):S100–S107PubMedCrossRefGoogle Scholar
  11. 11.
    Gelb DE, Lenke LG, Bridwell KH, Blanke K, McEnery KW (1995) An analysis of sagittal spinal alignment in 100 asymptomatic middle and older aged volunteers. Spine 20:1351–1358PubMedCrossRefGoogle Scholar
  12. 12.
    Gill JB, Levin A, Burd T, Longley M (2008) Corrective osteotomies in spine surgery. J Bone Joint Surg Am 90(11):2509–2520PubMedCrossRefGoogle Scholar
  13. 13.
    Glassman SD, Berven S, Bridwell K, Horton W, Dimar JR (2005) Correlation of radiographic parameters and clinical symptoms in adult scoliosis. Spine 30:682–688PubMedCrossRefGoogle Scholar
  14. 14.
    Heary RF, Kumar S, Bono CM (2008) Decision making in adult deformity. Neurosurgery 63(3):69–77PubMedCrossRefGoogle Scholar
  15. 15.
    Jackson RP, Hales C (2000) Congruent spinopelvic alignment on standing lateral radiographs of adult volunteers. Spine 25:2808–2815PubMedCrossRefGoogle Scholar
  16. 16.
    Jackson RP, McManus AC (1994) Radiographic analysis of sagittal plane alignment and balance in standing volunteers and patients with low back pain matched for age, sex, and size. A prospective controlled clinical study. Spine 19:1611–1618PubMedCrossRefGoogle Scholar
  17. 17.
    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 34:599–606CrossRefGoogle Scholar
  18. 18.
    Lafage V, Schwab F, Vira S, Patel A, Ungar B, Farcy JP (2011) Spinopelvic parameters after surgery can be predicted: a preliminary formula and validation of standing alignment. Spine 36:1037–1045PubMedCrossRefGoogle Scholar
  19. 19.
    Lamartina C, Berjano P, Petruzzi M, Sinigaglia A, Casero G, Cecchinato R, Damilano M, Bassani R (2012) Criteria to restore sagittal balance in deformity and degenerative spondylolisthesis. Eur Spine J 21:27–31CrossRefPubMedCentralGoogle Scholar
  20. 20.
    Lamartina C, Berjano P (2014) Classification of sagittal imbalance based on spinal alignment and compensatory mechanism. Eur Spine J 23(6):1177–1189PubMedCrossRefGoogle Scholar
  21. 21.
    Lazennec JY, Ramaré S, Arafati N, Laudet CG, Gorin M, Roger B, Hansen S, Saillant G, Maurs L, Trabelsi R (2000) Sagittal alignment in lumbosacral fusion: relations between radiological parameters and pain. Eur Spine J 9:47–55PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Le Huec JC, Leijssen P, Duarte M, Aunoble S (2011) Thoracolumbar imbalance analysis for osteotomy planification using a new method: FBI technique. Eur Spine J 20(5):669–680PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Mac-Thiong JM, Roussouly P, Berthonnaud E, Guigui P (2010) Sagittal parameters of global spinal balance: normative values from a prospective cohort of seven hundred nine Caucasian asymptomatic adults. Spine 35:1193–1198CrossRefGoogle Scholar
  24. 24.
    Mac-Thiong JM, Transfeldt EE, Mehbod AA, Perra JH, Denis F, Garvey TA, Lonstein JE, Wu C, Dorman CW, Winter RB (2009) Can C7 plumbline and gravity line predict health related quality of life in adult scoliosis? Spine 34(15):519–527CrossRefGoogle Scholar
  25. 25.
    Mehta VA, Amin A, Omeis I, Gokaslan ZL, Gottfried ON (2012) Implications of spinopelvic alignment for the spine surgeon. Neurosurgery 70:707–721PubMedCrossRefGoogle Scholar
  26. 26.
    Mi Kyung K, Sun-Ho L, Eun-Sang K, Whan E, Sung-Soo C, Chong-Suh L (2011) The impact of sagittal balance on clinical results after posterior interbody fusion for patients with degenerative spondylolisthesis: a pilot study. BMC Musculoskelet Disord 12:69. doi: 10.1186/1471-2474-12-69 CrossRefGoogle Scholar
  27. 27.
    Neal CJ, McClendon J, Halpin R, Acosta FL, Koski T, Ondra SL (2011) Predicting ideal spinopelvic balance in adult spinal deformity. J Neurosurg Spine 15:82–91PubMedCrossRefGoogle Scholar
  28. 28.
    Ondra SL, Marzouk S, Koski T, Silva F, Salehi S (2006) Mathematical calculation of pedicle subtraction osteotomy size to allow precision correction of fixed sagittal deformity. Spine 31:973–979CrossRefGoogle Scholar
  29. 29.
    Rose PS, Bridwell KH, Lenke LG, Cronen GA, Mulconrey DS, Buchowski JM, Kim YJ (2009) Role of pelvic incidence, thoracic kyphosis, and patient factors on sagittal plane correction following pedicle subtraction osteotomy. Spine 34:785–791PubMedCrossRefGoogle Scholar
  30. 30.
    Roussouly P, Nnadi C (2010) Sagittal plane deformity: an overview of interpretation and management. Eur Spine J 19:1824–1836PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Schwab F, Dubey A, Gamez L, El Fegoun AB, Hwang K, Pagala M, Farcy JP (2005) Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine 30:1082–1085PubMedCrossRefGoogle Scholar
  32. 32.
    Schwab F, Lafage V, Patel A, Farcy JP (2009) Sagittal plane considerations and the pelvis in the adult patient. Spine 34:1828–1833PubMedCrossRefGoogle Scholar
  33. 33.
    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 35:2224–2231PubMedCrossRefGoogle Scholar
  34. 34.
    Smith JS, Shaffrey CI, Berven S, Glassman S, Hamill C, Horton W, Ondra S, Schwab F, Shainline M, Fu KM, Bridwell K (2009) Improvement of back pain with operative and non operative in adults with scoliosis. Neurosurgery 65:86–93PubMedCrossRefGoogle Scholar
  35. 35.
    Smith JS, Shaffrey CI, Glassman SD, Berven SH, Schwab FJ, Hamill CL, Horton WC, Ondra SL, Sansur CA, Bridwell KH (2011) Risk-benefit assessment of surgery for adult scoliosis: an analysis based on patient age. Spine 36:817–824PubMedCrossRefGoogle Scholar
  36. 36.
    Smith-Petersen MN, Larson CB, Aufranc OE (1969) Osteotomy of the spine for correction of flexion deformity in rheumatoid arthritis. Clin Orthop Relat Res 66:6–9PubMedGoogle Scholar
  37. 37.
    Vaz G, Roussouly P, Berthonnaud E, Dimnet J (2002) Sagittal morphology and equilibrium of pelvis and spine. Eur Spine J 11:80–87PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Vialle R, Levassor N, Rillardon L, Templier A, Skalli W, Guigui P (2005) Radiographic analysis of the sagittal alignment and balance of the spine in asymptomatic subjects. J Bone Joint Surg 87:260–267PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Diego Garbossa
    • 1
  • Matteo Pejrona
    • 2
  • Marco Damilano
    • 2
  • Valerio Sansone
    • 3
  • Alessandro Ducati
    • 1
  • Pedro Berjano
    • 2
  1. 1.Division of Neurosurgery, Dipartimento di NeuroscienzeA.O. Città della Salute e della Scienza, Presidio MolinetteTurinItaly
  2. 2.IVth Spine Surgery DepartmentIRCSS Istituto Ortopedico GaleazziMilanItaly
  3. 3.Orthopaedic Clinic DepartmentUniversity of Milan, IRCSS Istituto Ortopedico GaleazziMilanItaly

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