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Relationship between pelvic incidence-adjusted relative spinopelvic parameters, global sagittal alignment and lower extremity compensations

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Abstract

Purpose

In response to sagittal malalignment, compensatory spinal and lower extremity mechanisms are recruited. Thoracolumbar realignment surgery has been shown to yield reciprocal changes in these compensations. Thus, whole-body radiographic assessment has come to the fore. This study aimed to evaluate the relationship between spinopelvic parameters and lower extremity compensation angles and to examine their coupled change with deformity correction.

Methods

This was a multicenter retrospective analysis of patients who had ≥ 4 levels posterior fusion, whole-body radiographs, and ≥ 2 years follow-up. Relative Pelvic Version (RPV), Relative Lumbar Lordosis (RLL), Relative Spinopelvic Alignment (RSA), Femoral Obliquity Angle (FOA), Knee Flexion Angle (KFA) and Global Sagittal Axis (GSA) were measured preoperatively and 6 week postoperatively. Kruskal–Wallis tests were performed to assess the relation of relative spinopelvic parameters to global sagittal alignment and lower extremity compensation angles. Spearman’s correlations were performed to assess correlations of pre-to-postoperative changes.

Results

193 patients (156F, 37 M) were included. The mean age was 57.2 ± 16.6 years. The mean follow-up duration was 50.6 (24–90) months. On average, 10.3 ± 3.8 levels were fused. Among the cohort, 124 (64.2%) had a sacral or sacroiliac fixation, and 43 (22.3%) had 3-column osteotomies. Preoperative FOA, KFA and GSA significantly differed between RPV, RLL and RSA categories. Significant weak-to-strong correlations were observed between spinopelvic parameters, global sagittal alignment and lower extremity compensation angles (rho range: − 0.351 to 0.767).

Conclusions

PI-adjusted relative spinopelvic parameters significantly correlated with measurements of the lower extremity compensation. Postoperative changes in RPV, RLL and RSA reflected changes in FOA, KFA and GSA. These measurements may serve as a valuable proxy for surgical planning when whole-body imaging is not available.

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References

  1. 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 35:2224–2231. https://doi.org/10.1097/BRS.0b013e3181ee6bd4

    Article  PubMed  Google Scholar 

  2. 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 

  3. 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. https://doi.org/10.1097/BRS.0b013e31817886a2

    Article  PubMed  Google Scholar 

  4. Ferrero E, Liabaud B, Challier V, Lafage R, Diebo BG, Vira S, Liu S, Vital JM, Ilharreborde B, Protopsaltis TS, Errico TJ, Schwab FJ, Lafage V (2016) Role of pelvic translation and lower-extremity compensation to maintain gravity line position in spinal deformity. J Neurosurg Spine 24:436–446. https://doi.org/10.3171/2015.5.SPINE14989

    Article  PubMed  Google Scholar 

  5. Amabile C, Le Huec JC, Skalli W (2018) Invariance of head-pelvis alignment and compensatory mechanisms for asymptomatic adults older than 49 years. Eur Spine J 27:458–466. https://doi.org/10.1007/s00586-016-4830-8

    Article  PubMed  Google Scholar 

  6. Lafage R, Liabaud B, Diebo BG, Oren JH, Vira S, Pesenti S, Protopsaltis TS, Errico TJ, Schwab FJ, Lafage V (2017) Defining the role of the lower limbs in compensating for sagittal malalignment. Spine 42:E1282–E1288. https://doi.org/10.1097/BRS.0000000000002157

    Article  PubMed  Google Scholar 

  7. El Fegoun AB, Schwab F, Gamez L, Champain N, Skalli W, Farcy JP (2005) Center of gravity and radiographic posture analysis: a preliminary review of adult volunteers and adult patients affected by scoliosis. Spine 30:1535–1540. https://doi.org/10.1097/01.brs.0000167534.49069.e9

    Article  PubMed  Google Scholar 

  8. Diebo BG, Ferrero E, Lafage R, Challier V, Liabaud B, Liu S, Vital JM, Errico TJ, Schwab FJ, Lafage V (2015) Recruitment of compensatory mechanisms in sagittal spinal malalignment is age and regional deformity dependent: a full-standing axis analysis of key radiographical parameters. Spine 40:642–649. https://doi.org/10.1097/BRS.0000000000000844

    Article  PubMed  Google Scholar 

  9. Diebo BG, Oren JH, Challier V, Lafage R, Ferrero E, Liu S, Vira S, Spiegel MA, Harris BY, Liabaud B, Henry JK, Errico TJ, Schwab FJ, Lafage V (2016) Global sagittal axis: a step toward full-body assessment of sagittal plane deformity in the human body. J Neurosurg Spine 25:494–499. https://doi.org/10.3171/2016.2.SPINE151311

    Article  PubMed  Google Scholar 

  10. Teraguchi M, Kawakami M, Ishimoto Y, Nagata K, Nakagawa M, Minetama M, Matsuo S, Nakagawa Y (2021) Sagittal imbalance of the spine-pelvis-lower extremity axis associated with back-related disability. J Orthop Sci 26:986–991. https://doi.org/10.1016/j.jos.2020.10.014

    Article  PubMed  Google Scholar 

  11. Day LM, Ramchandran S, Jalai CM, Diebo BG, Liabaud B, Lafage R, Protopsaltis T, Passias PG, Schwab FJ, Bess S, Errico TJ, Lafage V, Buckland AJ (2017) Thoracolumbar realignment surgery results in simultaneous reciprocal changes in lower extremities and cervical spine. Spine 42:799–807. https://doi.org/10.1097/BRS.0000000000001928

    Article  PubMed  Google Scholar 

  12. Shimizu T, Lehman RA Jr, Sielatycki JA, Pongmanee S, Cerpa M, Takemoto M, Lenke LG (2020) Reciprocal change of sagittal profile in unfused spinal segments and lower extremities after complex adult spinal deformity surgery including spinopelvic fixation: a full-body X-ray analysis. Spine J Off J North Am Spine Soc 20:380–390. https://doi.org/10.1016/j.spinee.2019.09.012

    Article  Google Scholar 

  13. Yilgor C, Sogunmez N, Boissiere L, Yavuz Y, Obeid I, Kleinstuck F, Perez-Grueso FJS, Acaroglu E, Haddad S, Mannion AF, Pellise F, Alanay A, European Spine Study G (2017) Global alignment and proportion (GAP) score: development and validation of a new method of analyzing spinopelvic alignment to predict mechanical complications after adult spinal deformity surgery. J Bone Joint Surg Am 99:1661–1672. https://doi.org/10.2106/JBJS.16.01594

    Article  PubMed  Google Scholar 

  14. Yilgor C, Sogunmez N, Yavuz Y, Abul K, Boissiere L, Haddad S, Obeid I, Kleinstuck F, Sanchez Perez-Grueso FJ, Acaroglu E, Mannion AF, Pellise F, Alanay A, European Spine Study G (2017) Relative lumbar lordosis and lordosis distribution index: individualized pelvic incidence-based proportional parameters that quantify lumbar lordosis more precisely than the concept of pelvic incidence minus lumbar lordosis. Neurosurg Focus 43:E5. https://doi.org/10.3171/2017.8.FOCUS17498

    Article  PubMed  Google Scholar 

  15. Obeid I, Hauger O, Aunoble S, Bourghli A, Pellet N, Vital JM (2011) Global analysis of sagittal spinal alignment in major deformities: correlation between lack of lumbar lordosis and flexion of the knee. Eur Spine J 20(Suppl 5):681–685. https://doi.org/10.1007/s00586-011-1936-x

    Article  PubMed  PubMed Central  Google Scholar 

  16. Yilgor C, Yavuz Y, Sogunmez N, Haddad S, Mannion AF, Abul K, Boissiere L, Obeid I, Kleinstuck F, Perez-Grueso FJS, Acaroglu E, Pellise F, Alanay A, European Spine Study G (2018) Relative pelvic version: an individualized pelvic incidence-based proportional parameter that quantifies pelvic version more precisely than pelvic tilt. Spine J 18:1787–1797. https://doi.org/10.1016/j.spinee.2018.03.001

    Article  PubMed  Google Scholar 

  17. Quarto E, Zanirato A, Pellegrini M, Vaggi S, Vitali F, Bourret S, Le Huec JC, Formica M (2022) GAP score potential in predicting post-operative spinal mechanical complications: a systematic review of the literature. Eur Spine J. https://doi.org/10.1007/s00586-022-07386-6

    Article  PubMed  Google Scholar 

  18. Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16:494–502. https://doi.org/10.1136/ard.16.4.494

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Dubousset J (1994) Three-dimensional analysis of the scoliotic deformity. In: Weinstein S (ed) The pediatric spine: principles and practice. Raven Press, New York, pp 479–496

    Google Scholar 

  20. Verma R, Lafage R, Scheer J, Smith J, Passias P, Hostin R, Ames C, Mundis G, Burton D, Kim HJ, Bess S, Klineberg E, Schwab F, Lafage V, International Spine Study G (2019) Improvement in back and leg pain and disability following adult spinal deformity surgery: study of 324 patients with 2-year follow-up and the impact of surgery on patient-reported outcomes. Spine 44:263–269. https://doi.org/10.1097/BRS.0000000000002815

    Article  PubMed  Google Scholar 

  21. Passias PG, Jalai CM, Diebo BG, Cruz DL, Poorman GW, Buckland AJ, Day LM, Horn SR, Liabaud B, Lafage R, Soroceanu A, Baker JF, McClelland S 3rd, Oren JH, Errico TJ, Schwab FJ, Lafage V (2019) Full-body radiographic analysis of postoperative deviations from age-adjusted alignment goals in adult spinal deformity correction and related compensatory recruitment. Int J Spine Surg 13:205–214. https://doi.org/10.14444/6028

    Article  PubMed  PubMed Central  Google Scholar 

  22. Le Huec JC, Thompson W, Mohsinaly Y, Barrey C, Faundez A (2019) Sagittal balance of the spine. Eur Spine J 28:1889–1905. https://doi.org/10.1007/s00586-019-06083-1

    Article  PubMed  Google Scholar 

  23. Qian BP, Jiang J, Qiu Y, Wang B, Yu Y, Zhu ZZ (2014) The presence of a negative sacral slope in patients with ankylosing spondylitis with severe thoracolumbar kyphosis. J Bone Joint Surg Am 96:e188. https://doi.org/10.2106/JBJS.M.01070

    Article  PubMed  Google Scholar 

  24. Tsuji T, Matsuyama Y, Goto M, Yimin Y, Sato K, Hasegawa Y, Ishiguro N (2002) Knee-spine syndrome: correlation between sacral inclination and patellofemoral joint pain. J Orthop Sci 7:519–523. https://doi.org/10.1007/s007760200092

    Article  PubMed  Google Scholar 

  25. Tauchi R, Imagama S, Muramoto A, Tsuboi M, Ishiguro N, Hasegawa Y (2015) Influence of spinal imbalance on knee osteoarthritis in community-living elderly adults. Nagoya J Med Sci 77:329–337

    PubMed  PubMed Central  Google Scholar 

  26. Shimizu T, Cerpa M, Lenke LG (2021) Understanding sagittal compensation in adult spinal deformity patients: relationship between pelvic tilt and lower-extremity position. Journal Neurosurg Spine. https://doi.org/10.3171/2021.1.SPINE201660

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey

    Altug Yucekul, Caglar Yilgor & Ahmet Alanay

  2. Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Alp Ozpinar & Nallammai Muthiah

  3. Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey

    Fevzi Duhan Berkan Kilickan & Mohammed Dalla

  4. Comprehensive Spine Center, Acibadem University Maslak Hospital, Istanbul, Turkey

    Tais Zulemyan & Ahmet Alanay

  5. Department of Biostatistics, Ankara University School of Medicine, Ankara, Turkey

    Yasemin Yavuz

  6. Spine Unit, Orthopaedic Surgery Department, Hospital Universitario La Paz, Madrid, Spain

    Javier Pizones & Francisco Javier Sánchez Pérez-Grueso

  7. Spine Surgery Unit, Bordeaux University Hospital, Bordeaux, France

    Ibrahim Obeid

  8. Spine Center Division, Department of Orthopedics and Neurosurgery, Schulthess Klinik, Zurich, Switzerland

    Frank Kleinstück

  9. Spine Surgery Unit, Hospital Universitari Vall d’Hebron, Barcelona, Spain

    Ferran Pellisé

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  1. Altug Yucekul
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Correspondence to Ahmet Alanay.

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Yucekul, A., Ozpinar, A., Kilickan, F.D.B. et al. Relationship between pelvic incidence-adjusted relative spinopelvic parameters, global sagittal alignment and lower extremity compensations. Eur Spine J 32, 3599–3607 (2023). https://doi.org/10.1007/s00586-023-07677-6

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