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

Abstract

Introduction

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.

Methods

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

Results

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.

Conclusions

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.

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Abbreviations

LL:

Lumbar lordosis

PI:

Pelvic incidence

PT:

Pelvic tilt

SS:

Sacral slope

TK:

Thoracic kyphosis

References

  1. 1.

    Barrey C (2004) Equilibre sagittal pelvi-rachidien et pathologies lombaires dégénératives. Etude comparative à propos de 100 cas (in French). Thèse de Médecine. Université Claude Bernard, Lyon

  2. 2.

    Barrey C, Jund J, Noseda O, Roussouly P (2007) Sagittal balance of the pelvis–spine complex and lumbar degenerative diseases. A comparative study about 85 cases. Eur Spine J 16:1459–1467

    PubMed  Article  Google Scholar 

  3. 3.

    Barrey C, Jund J, Perrin G, Roussouly P (2007) Spinopelvic alignment of patients with degenerative spondylolisthesis. Neurosurg 61:981–986

    Article  Google Scholar 

  4. 4.

    Berthonnaud E, Dimnet J, Roussouly P, Labelle H (2005) Analysis of the sagittal spine and pelvis using shape and orientation parameters. J Spinal Disord Tech 18:40–47

    PubMed  Article  Google Scholar 

  5. 5.

    During J, Goudfrooij H, Keessen W, Beeker TW, Crowe A (1985) Towards standards for posture. Postural characteristics of the lower back system in normal and pathologic conditions. Spine 10:83–87

    PubMed  Article  CAS  Google Scholar 

  6. 6.

    Duval-Beaupère G, Legaye J (2004) Composante sagittale de la statique rachidienne (in French). Rev Rhum 71:105–119

    Article  Google Scholar 

  7. 7.

    Gelb DE, Lenke LG, Bridwell KH, Blanke K, MacEnery KW (1995) An analysis of sagittal spinal aligment in 100 asymptomatic middle and older aged volunteers. Spine 20:1351–1358

    PubMed  CAS  Google Scholar 

  8. 8.

    Guigui P, Levassor N, Rillardon L, Wodecki P, Cardinne L (2003) Valeur physiologique des paramètres pelviens et rachidiens de l’équilibre sagittal du rachis. Analyse d’une série de 250 volontaires (in French). Rev Chir Orthop 89:496–506

    PubMed  CAS  Google Scholar 

  9. 9.

    Izumi Y, Kumano K (2001) Analysis of sagittal lumbar alignment before and after posterior instrumentation: risk factor for adjacent unfused segment. Eur J Orthop Surg Traum 1:9–13

    Article  Google Scholar 

  10. 10.

    Jackson RP, MacManus 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. Spine 19:1611–1618

    PubMed  Article  CAS  Google Scholar 

  11. 11.

    Jackson RP, Kanemura T, Kawakami N, Hales C (2000) Lumbopelvic lordosis and pelvic balance on repeated standing lateral radiographs of adult volunteers and untreated patients with constant low back pain. Spine 25:575–586

    PubMed  Article  CAS  Google Scholar 

  12. 12.

    Kobayashi T, Atsuta Y, Matsuno T, Takeda N (2004) A longitudinal study of congruent sagittal spinal alignment in an adult cohort. Spine 29:671–676

    PubMed  Article  Google Scholar 

  13. 13.

    Korovessis PG, Stamatakis MV, Baikousis AG (1998) Reciprocal angulation of vertebral bodies in the sagittal plane in a asymptomatic Greek population. Spine 23:700–704

    PubMed  Article  CAS  Google Scholar 

  14. 14.

    Korovessis PG, Dimas A, Iliopoulos P, Lambiris E (2002) Correlative analysis of lateral vertebral radiographic variables and medical outcomes study short-form health survey: a comparative study in asymptomatic volunteers versus patients with low back pain. J Spinal Disord Tech 15:384–390

    PubMed  Article  Google Scholar 

  15. 15.

    Kumar MN, Baklanov A, Chopin D (2001) Correlation between sagittal plane changes and adjacent segment degeneration following lumbar spine fusion. Eur Spine J 10:314–319

    PubMed  Article  CAS  Google Scholar 

  16. 16.

    Lafage V, Schwab F, Skalli W, Hawkinson N, Gagey PM, Ondra S, Farcy JP (2008) Standing balance and sagittal plane spinal deformity: analysis of spinopelvic and gravity line parameters. Spine 33:1572–1578

    PubMed  Article  Google Scholar 

  17. 17.

    Lazennec JY, Ramare 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 9:47–55

    PubMed  Article  CAS  Google Scholar 

  18. 18.

    Legaye J, Duval-Beaupère G, Hecquet J, Marty C (1998) Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves. Eur Spine J 7:99–103

    PubMed  Article  CAS  Google Scholar 

  19. 19.

    Mangione P, Senegas J (1997) L’équilibre rachidien dans le plan sagittal (in French). Rev Chir Orthop 83:22–32

    PubMed  CAS  Google Scholar 

  20. 20.

    Marnay T (1988) Equilibre du rachis et du bassin. Cahiers d’enseignement de la SOFCOT. Elsevier, Paris, pp 281–313

  21. 21.

    Rajnics P, Templier A, Skalli W, Lavaste F, Illes T (2002) The importance of spinopelvic parameters in patients with lumbar disc lesions. Int Orthop 26:104–108

    PubMed  Article  CAS  Google Scholar 

  22. 22.

    Roussouly P, Gollogly S, Berthonnaud E, Dimnet J (2005) Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine 30:346–353

    PubMed  Article  Google Scholar 

  23. 23.

    Roussouly P, Gollogly S, Noseda O, Berthonnaud E, Dimnet J (2006) The vertical projection of the sum of the ground reactive forces of a standing patient is not the same as the C7 plumbline: a radiographic study of the sagittal alignment of 153 asymptomatic volunteers. Spine 31:E320–E325

    PubMed  Article  Google Scholar 

  24. 24.

    Stagnara P, De Mauroy JC, Dran G, Gonon G, Costanzo G, Dimnet J, Pasquet A (1982) Reciprocal angulation of vertebral bodies in a sagittal plane: approach to references for the evaluation of kyphosis and lordosis. Spine 7:335–342

    PubMed  Article  CAS  Google Scholar 

  25. 25.

    Vaz G, Roussouly P, Berthonnaud E, Dimnet J (2002) Sagittal morphology and equilibrium of pelvis and spine. Eur Spine J 11:80–87

    PubMed  Article  CAS  Google Scholar 

  26. 26.

    Vital JM, Gille O, Gangnet N (2004) Equilibre sagittal et applications cliniques (in French). Rev Rhum 71:120–128

    Article  Google Scholar 

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Conflict of interest

No funds were received in support of this study.

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Correspondence to Cédric Barrey.

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Barrey, C., Roussouly, P., Perrin, G. et al. Sagittal balance disorders in severe degenerative spine. Can we identify the compensatory mechanisms?. Eur Spine J 20, 626 (2011). https://doi.org/10.1007/s00586-011-1930-3

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Keywords

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