European Spine Journal

, 20:626 | Cite as

Sagittal balance disorders in severe degenerative spine. Can we identify the compensatory mechanisms?

  • Cédric BarreyEmail author
  • Pierre Roussouly
  • Gilles Perrin
  • Jean-Charles Le Huec
Review Article



Aging of the spine is characterized by facet joints arthritis, degenerative disc disease and atrophy of extensor muscles resulting in a progressive kyphosis. Recent studies confirmed that patients with lumbar degenerative disease were characterized by an anterior sagittal imbalance, a loss of lumbar lordosis and an increase of pelvis tilt. The aim of this paper was thus to describe the different compensatory mechanisms which are observed in the spine, pelvis and/or lower limbs areas for patients with severe degenerative spine.


We reviewed all the compensatory mechanisms of sagittal unbalance described in the literature.


According to the severity of the imbalance, we could identify three different stages: balanced, balanced with compensatory mechanisms and imbalanced. For the two last stages, the compensatory mechanisms permitted to limit consequences of lumbar kyphosis on the global sagittal alignment. Reduction of thoracic kyphosis, intervertebral hyperextension, retrolisthesis, pelvis backtilt, knee flessum and ankle extension were the main mechanisms described in the literature. The basic concept of these compensatory mechanisms was to extend adjacent segments of the kyphotic spine allowing for compensation of anterior translation of the axis of gravity.


To avoid underestimate the severity of the degenerative spine disorder, it thus seems important to recognize the different compensatory mechanisms from the upper part of the trunk to the lower limbs. We propose a three steps algorithm to analyse the balance status and determine the presence or not of these compensatory mechanisms: measurement of pelvis incidence, assessment of global sagittal alignment and analysis of compensatory mechanisms successively in the spine, pelvis and lower limbs areas.


Sagittal balance Pelvis Spinal alignment Lumbar lordosis Degenerative disc disease Lumbar kyphosis 



Lumbar lordosis


Pelvic incidence


Pelvic tilt


Sacral slope


Thoracic kyphosis


Conflict of interest

No funds were received in support of this study.


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Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Cédric Barrey
    • 1
    • 2
    • 5
    Email author
  • Pierre Roussouly
    • 3
  • Gilles Perrin
    • 1
  • Jean-Charles Le Huec
    • 4
  1. 1.Department of Neurosurgery C and Spine SurgeryNeurological HospitalLyonFrance
  2. 2.Laboratory of BiomechanicsENSAM, Arts et Metiers ParisTechParisFrance
  3. 3.Department of Orthopedic SurgeryClinique médico-chirurgicale des MassuesLyonFrance
  4. 4.Spine unit 2, Deterca Surg lab, Department of Orthopedic SurgeryUniversity HospitalBordeauxFrance
  5. 5.LyonFrance

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