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Han Jo Kim - One of the best experts on this subject based on the ideXlab platform.
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effective prevention of proximal junctional failure in adult spinal deformity surgery requires a combination of surgical implant prophylaxis and avoidance of Sagittal Alignment overcorrection
Spine, 2020Co-Authors: Breton Line, Renaud Lafage, Frank J Schwab, Han Jo Kim, Munish C Gupta, Shay Bess, V Lafage, Christopher P Ames, Michael J Kelly, Douglas BurtonAbstract:STUDY DESIGN Propensity score matched analysis of a multi-center prospective adult spinal deformity (ASD) database. OBJECTIVE Evaluate if surgical implant prophylaxis combined with avoidance of Sagittal overcorrection more effectively prevents proximal junctional failure (PJF) than use of surgical implants alone. SUMMARY OF BACKGROUND DATA PJF is a severe form of proximal junctional kyphosis (PJK). Efforts to prevent PJF have focused on use of surgical implants. Less information exists on avoidance of overcorrection of age-adjusted Sagittal Alignment to prevent PJF. METHODS Surgically treated ASD patients (age ≥18 yrs; ≥5 levels fused, ≥1 year follow-up) enrolled into a prospective multi-center ASD database were propensity score matched (PSM) to control for risk factors for PJF. Patients evaluated for use of surgical implants to prevent PJF (IMPLANT) versus no implant prophylaxis (NONE), and categorized by the type of implant used (CEMENT, HOOK, TETHER). Postoperative Sagittal Alignment was evaluated for overcorrection of age-adjusted Sagittal Alignment (OVER) versus within Sagittal parameters (ALIGN). Incidence of PJF was evaluated at minimum 1 year postop. RESULTS Six hundred twenty five of 834 eligible for study inclusion were evaluated. Following PSM to control for confounding variables, analysis demonstrated the incidence of PJF was lower for IMPLANT (n = 235; 10.6%) versus NONE (n = 390: 20.3%; P < 0.05). Use of transverse process hooks at the upper instrumented vertebra (HOOK; n = 115) had the lowest rate of PJF (7.0%) versus NONE (20.3%; P < 0.05). ALIGN (n = 246) had lower incidence of PJF than OVER (n = 379; 12.0% vs. 19.2%, respectively; P < 0.05). The combination of ALIGN-IMPLANT further reduced PJF rates (n = 81; 9.9%), while OVER-NONE had the highest rate of PJF (n = 225; 24.2%; P < 0.05). CONCLUSION Propensity score matched analysis of 625 ASD patients demonstrated use of surgical implants alone to prevent PJF was less effective than combining implants with avoidance of Sagittal overcorrection. Patients that received no PJF implant prophylaxis and had Sagittal overcorrection had the highest incidence of PJF. LEVEL OF EVIDENCE 3.
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thoracolumbar junction orientation its impact on thoracic kyphosis and Sagittal Alignment in both asymptomatic volunteers and symptomatic patients
European Spine Journal, 2019Co-Authors: Hong Joo Moon, Keith H Bridwell, Alekos A Theologis, Micheal P Kelly, Thamrong Lertudomphonwanit, Han Jo Kim, Lawrence G Lenke, Munish C GuptaAbstract:The thoracolumbar junction (TLJ) has not been explored in regard to its contribution to global Sagittal Alignment. This study aims to define novel Sagittal parameters of the TLJ and to assess their roles within global Sagittal Alignment. Included for cross-sectional, retrospective analysis were asymptomatic volunteers and symptomatic patients who had undergone operation for adult spinal deformity. Unique Sagittal parameters of the TLJ were measured using the midline of the T12–L1 disk space: The TLJ orientation [TLJO; thoracolumbar tilt (TLT) and slope (TLS)]. Thoracic kyphosis (TK; T5–12), C7–S1 Sagittal vertical axis (SVA), lumbar lordosis (LL; L1–S1), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI) were measured. Continuous variables were compared using the independent t test. Pearson correlations examined relationships between the parameters in each group. The asymptomatic TK was calculated using the measurement of the asymptomatic volunteer’s TLJO by linear regression. One hundred fifteen asymptomatic volunteers and 127 symptomatic patients were included. Only LL among the lumbopelvic parameters correlated with TK (asymptomatic volunteers: r = − 0.42; symptomatic patients: r = − 0.40). All the pelvic parameters have no direct correlation with TK in both groups. TLJO had stronger correlation with TK [asymptomatic volunteers: r = − 0.68 (TLS), r = 0.41 (TLT); symptomatic patients: r = − 0.56 (TLS), r = 0.44 (TLT)] than the lumbopelvic parameters. TLS correlated with LL (asymptomatic volunteers: r = 0.78; symptomatic patients: r = 0.73). Most pelvic parameters correlated with TLJO except for PI. The asymptomatic TK was estimated by the derived formula: 20.847 + TLS × (− 1.198). The TLJO integrates the status of the lumbopelvic Sagittal parameters and simultaneously correlates with thoracic and global Sagittal Alignment. These slides can be retrieved under Electronic Supplementary Material.
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wednesday september 26 2018 3 35 pm 5 05 pm preserving spinal motion 86 successful clinical outcomes following surgery for severe cervical deformity are dependent upon achieving sufficient cervical Sagittal Alignment
The Spine Journal, 2018Co-Authors: Themistocles S Protopsaltis, Renaud Lafage, Han Jo Kim, Nicholas Stekas, Justin S Smith, Alexandra Soroceanu, Alan H Daniels, Peter G Passias, Gregory M Mundis, Eric O KlinebergAbstract:BACKGROUND CONTEXT Cervical malAlignment has been associated with increased disability. Both cSVA and C2S have been correlated to poor clinical outcomes. Surgical corrections of severe cervical deformities present considerable treatment challenges. Demographic, surgical and postoperative factors associated with failed radiographic and clinical outcomes have not been well established. PURPOSE To identify patients at risk of failure to restore Sagittal Alignment in cervical deformity corrective surgery. Additionally, to analyze how failure to restore Sagittal Alignment postoperatively affects patient reported outcomes and to determine the clinical significance of failure to correct malAlignment. STUDY DESIGN/SETTING Retrospective review of a prospective cohort of consecutively enrolled cervical deformity patients. PATIENT SAMPLE Sixty-six patients with severe cervical deformity at baseline (defined as>4 cm cSVA or >20°C2 slope) with one year radiographic follow-up. OUTCOME MEASURES Postoperative Sagittal Alignment parameters, health-related outcome measures, and surgical parameters. METHODS A prospective database of operative CD patients (inclusion criteria: cervical kyphosis >10°, cervical scoliosis >10°, cSVA>4 cm or CBVA>25°) was analyzed. Inclusion was restricted to severe baseline cervical deformities (cSVA>4 cm or C2 Slope (C2S)>20°) and 1-year follow-up. Failed surgery was defined as cSVA>4 cm at 1 year while successful surgery was defined as cSVA 7). RESULTS Sixty-six patients with severe CD met inclusion criteria, including 41 failed (62%) surgery and 25 successful. Failed surgery patients had worse Sagittal Alignment at baseline and 1 year by cSVA, C2S, T1S, TS-CL, and CTPA (p CONCLUSIONS Baseline cervical malAlignment, male gender and intra-operative blood loss were associated with failed radiographic outcomes in patients with severe cervical deformity. Failed surgery patients also had less improvement in NDI at 6 months and 1 year than successful surgeries. More patients with successful surgeries attained MCID for NDI at 6 months. In correcting severe CD, surgeons need to obtain optimal radiographic Alignment to attain better clinical outcomes. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.
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variations in Sagittal Alignment parameters based on age a prospective study of asymptomatic volunteers using full body radiographs
Spine, 2016Co-Authors: Sravisht Iyer, Lawrence G Lenke, Venu M Nemani, Todd J Albert, Brenda A Sides, Lionel N Metz, Matthew E Cunningham, Han Jo KimAbstract:STUDY DESIGN Cross-sectional cohort study. OBJECTIVE Describe age-stratified normative values of traditional and novel Sagittal Alignment parameters. SUMMARY OF BACKGROUND DATA Full-body radiographic techniques can capture coronal and Sagittal standing images from the occiput to the foot without stitching or vertical distortion. This provides an ideal method to evaluate measures of global Alignment. METHODS Adults with no back or neck symptoms were recruited. Age, body mass index, Neck Disability Index, and Oswestry Disability Index scores were recorded. The following parameters were measured: center sacral vertebral line, Occiput-C2 (O-C2) lordosis, cervical lordosis (C2-C7, CL), thoracic kyphosis (T2-12, TK), T2-T5 kyphosis, T5-T12 kyphosis, thoracolumbar kyphosis (T10-L2), lumbar lordosis (L1-S1, LL), sacral slope, pelvic tilt, pelvic incidence (PI), knee flexion angle, global Sagittal angle, T1-pelvis angle, C2-S1 Sagittal vertical axis (SVA), C7-S1 SVA, Basion-C7 SVA, B-S1 SVA and Basion to the center of the femoral head SVA and PI minus LL. Comparisons of Sagittal Alignment parameters between different age groups were performed. A Pearson correlation was used to determine relationships. RESULTS One hundred fifteen volunteers had imaging suitable for analysis; average age as 50.1 years (range 22-78), average body mass index was 28, average Neck Disability Index was 3.4 ± 4.4, and average Oswestry Disability Index was 1.7 ± 4.9. CL (r = -0.34, P = 0.001), T1-pelvis angle (r = 0.44, P < 0.001), knee flexion angle (r = 0.42, P < 0.001), global Sagittal angle (r = 0.56, P < 0.001), and C7 SVA (r = 0.46, P < 0.001) all increased with age. LL decreased with age (r = 0.212, P = 0.039). We were able to establish a chain of correlation extending from the toes to the occiput and report age-based normative values for all parameters. CONCLUSION We describe age-based normative Sagittal Alignment parameters in the adult spine with complete visualization from the occiput to the feet. We describe compensatory changes that occur to maintain Sagittal balance. These values may be used as a reference for future studies. LEVEL OF EVIDENCE 4.
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impact of cervical Sagittal Alignment parameters on neck disability
Spine, 2016Co-Authors: Sravisht Iyer, Venu M Nemani, Christopher P Ames, Joseph Nguyen, Jonathan Elysee, Aonnicha Burapachaisri, Han Jo KimAbstract:STUDY DESIGN Retrospective cross-sectional study. OBJECTIVE Determine if pre-operative cervical Alignment serves as an independent predictor of pre-operative disability as measured by the neck disability index (NDI). SUMMARY OF BACKGROUND DATA There is growing interest in the relationship between cervical Sagittal Alignment and clinical outcomes. While prior studies have shown that C2-C7 Sagittal vertical axis (SVA) correlates with worse NDI scores in post-operative patients, no studies to date have examined the impact of cervical Sagittal parameters on pre-operative disability in patients indicated for surgery. METHODS Patients with pre-operative standing cervical radiographs, no prior cervical spine procedures and a pre-operative NDI score were identified. Measurements were made by two observers at two different time points. Parameters measured were: Occiput-C2 angle, C1-C2 angle, C2-C7 angle (CL), T1 slope (TS), TS minus CL (TS-CL), C2-C7 SVA, and C1-C7 SVA. Intra- and inter-observer reliability was calculated. Subgroup analyses of myelopathy vs. radiculopathy and deformity vs. no deformity was performed. A multivariate linear regression was performed. RESULTS Ninety patients were included. Indications included cervical myelopathy (n = 63), cervical radiculopathy (n = 25), cervical stenosis (n = 9), and others (n = 5). CL averaged -13.7 ± 14.9 degrees. TS averaged 30.7 ± 10.4 degrees and C2-C7 SVA averaged 28.8 ± 13.2 mm. Intra- and inter-observer reliability was good to excellent (ICC > 0.8). Increasing CL (r = 0.277, P = 0.009), increasing TS (r = -0.273, P = 0.011) and increasing TS-CL (r = -0.301, P = 0.005) were correlated with decreasing NDI. CL, TS and TS-CL were also strongly correlated with each other (r > 0.65, P < 0.001 for all bivariate correlations). A multivariate regression adjusting for age and indication showed TS-CL (P = 0.040) and C2-C7 SVA (P = 0.015) were independent predictors of NDI. CONCLUSION Increasing CL, increasing TS and increasing TS-CL are correlated with decreasing pre-operative NDI. Low TS-CL and high C2-C7 SVA are independent predictors of high pre-operative NDI. LEVEL OF EVIDENCE 4.
Christopher P Ames - One of the best experts on this subject based on the ideXlab platform.
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effective prevention of proximal junctional failure in adult spinal deformity surgery requires a combination of surgical implant prophylaxis and avoidance of Sagittal Alignment overcorrection
Spine, 2020Co-Authors: Breton Line, Michael P Kelly, Renaud Lafage, Frank J Schwab, Munish C Gupta, Shay Bess, V Lafage, Christopher P Ames, Douglas Burton, Robert HartAbstract:STUDY DESIGN: Propensity score matched analysis of a multi-center prospective adult spinal deformity (ASD) database. OBJECTIVE: Evaluate if surgical implant prophylaxis combined with avoidance of Sagittal overcorrection more effectively prevents proximal junctional failure (PJF) than use of surgical implants alone. SUMMARY OF BACKGROUND DATA: PJF is a severe form of proximal junctional kyphosis (PJK). Efforts to prevent PJF have focused on use of surgical implants. Less information exists on avoidance of overcorrection of age-adjusted Sagittal Alignment to prevent PJF. METHODS: Surgically treated ASD patients (age ≥18 years; ≥5 levels fused, ≥1 year follow-up) enrolled into a prospective multi-center ASD database were propensity score matched (PSM) to control for risk factors for PJF. Patients evaluated for use of surgical implants to prevent PJF (IMPLANT) vs. no implant prophylaxis (NONE), and categorized by the type of implant used (CEMENT, HOOK, TETHER). Postoperative Sagittal Alignment was evaluated for overcorrection of age-adjusted Sagittal Alignment (OVER) vs. within Sagittal parameters (ALIGN). Incidence of PJF was evaluated at minimum 1 year postop. RESULTS: 625 of 834 eligible for study inclusion were evaluated. Following PSM to control for confounding variables, analysis demonstrated the incidence of PJF was lower for IMPLANT (n = 235; 10.6%) vs. NONE (n = 390: 20.3%; p < 0.05). Use of transverse process hooks at the upper instrumented vertebra (HOOK; n = 115) had the lowest rate of PJF (7.0%) vs. NONE (20.3%; p < 0.05). ALIGN (n = 246) had lower incidence of PJF than OVER (n = 379; 12.0% vs. 19.2%, respectively; p < 0.05). The combination of ALIGN-IMPLANT further reduced PJF rates (n = 81; 9.9%), while OVER-NONE had the highest rate of PJF (n = 225; 24.2%; p < 0.05). CONCLUSION: Propensity score matched analysis of 625 ASD patients demonstrated use of surgical implants alone to prevent PJF was less effective than combining implants with avoidance of Sagittal overcorrection. Patients that received no PJF implant prophylaxis and had Sagittal overcorrection had the highest incidence of PJF. LEVEL OF EVIDENCE: 3.
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effective prevention of proximal junctional failure in adult spinal deformity surgery requires a combination of surgical implant prophylaxis and avoidance of Sagittal Alignment overcorrection
Spine, 2020Co-Authors: Breton Line, Renaud Lafage, Frank J Schwab, Han Jo Kim, Munish C Gupta, Shay Bess, V Lafage, Christopher P Ames, Michael J Kelly, Douglas BurtonAbstract:STUDY DESIGN Propensity score matched analysis of a multi-center prospective adult spinal deformity (ASD) database. OBJECTIVE Evaluate if surgical implant prophylaxis combined with avoidance of Sagittal overcorrection more effectively prevents proximal junctional failure (PJF) than use of surgical implants alone. SUMMARY OF BACKGROUND DATA PJF is a severe form of proximal junctional kyphosis (PJK). Efforts to prevent PJF have focused on use of surgical implants. Less information exists on avoidance of overcorrection of age-adjusted Sagittal Alignment to prevent PJF. METHODS Surgically treated ASD patients (age ≥18 yrs; ≥5 levels fused, ≥1 year follow-up) enrolled into a prospective multi-center ASD database were propensity score matched (PSM) to control for risk factors for PJF. Patients evaluated for use of surgical implants to prevent PJF (IMPLANT) versus no implant prophylaxis (NONE), and categorized by the type of implant used (CEMENT, HOOK, TETHER). Postoperative Sagittal Alignment was evaluated for overcorrection of age-adjusted Sagittal Alignment (OVER) versus within Sagittal parameters (ALIGN). Incidence of PJF was evaluated at minimum 1 year postop. RESULTS Six hundred twenty five of 834 eligible for study inclusion were evaluated. Following PSM to control for confounding variables, analysis demonstrated the incidence of PJF was lower for IMPLANT (n = 235; 10.6%) versus NONE (n = 390: 20.3%; P < 0.05). Use of transverse process hooks at the upper instrumented vertebra (HOOK; n = 115) had the lowest rate of PJF (7.0%) versus NONE (20.3%; P < 0.05). ALIGN (n = 246) had lower incidence of PJF than OVER (n = 379; 12.0% vs. 19.2%, respectively; P < 0.05). The combination of ALIGN-IMPLANT further reduced PJF rates (n = 81; 9.9%), while OVER-NONE had the highest rate of PJF (n = 225; 24.2%; P < 0.05). CONCLUSION Propensity score matched analysis of 625 ASD patients demonstrated use of surgical implants alone to prevent PJF was less effective than combining implants with avoidance of Sagittal overcorrection. Patients that received no PJF implant prophylaxis and had Sagittal overcorrection had the highest incidence of PJF. LEVEL OF EVIDENCE 3.
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Sagittal Alignment and complications following lumbar 3 column osteotomy does the level of resection matter
Journal of Neurosurgery, 2017Co-Authors: Emmanuelle Ferrero, Munish C Gupta, Gregory M Mundis, Christopher P Ames, Barthelemy Liabaud, Jensen K Henry, Khaled M Kebaish, Richard A Hostin, Oheneba Boachieadjei, Justin S SmithAbstract:OBJECTIVEThree-column osteotomy (3CO) is a demanding technique that is performed to correct Sagittal spinal malAlignment. However, the impact of the 3CO level on pelvic or truncal Sagittal correction remains unclear. In this study, the authors assessed the impact of 3CO level and postoperative apex of lumbar lordosis on Sagittal Alignment correction, complications, and revisions.METHODSIn this retrospective study of a multicenter spinal deformity database, radiographic data were analyzed at baseline and at 1- and 2-year follow-up to quantify spinopelvic Alignment, apex of lordosis, and resection angle. The impact of 3CO level and apex level of lumbar lordosis on the Sagittal correction was assessed. Logistic regression analyses were performed, controlling for cofounders, to investigate the effects of 3CO level and apex level on intraoperative and postoperative complications as well as on the need for subsequent revision surgery.RESULTSA total of 468 patients were included (mean age 60.8 years, mean body m...
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impact of cervical Sagittal Alignment parameters on neck disability
Spine, 2016Co-Authors: Sravisht Iyer, Venu M Nemani, Christopher P Ames, Joseph Nguyen, Jonathan Elysee, Aonnicha Burapachaisri, Han Jo KimAbstract:STUDY DESIGN Retrospective cross-sectional study. OBJECTIVE Determine if pre-operative cervical Alignment serves as an independent predictor of pre-operative disability as measured by the neck disability index (NDI). SUMMARY OF BACKGROUND DATA There is growing interest in the relationship between cervical Sagittal Alignment and clinical outcomes. While prior studies have shown that C2-C7 Sagittal vertical axis (SVA) correlates with worse NDI scores in post-operative patients, no studies to date have examined the impact of cervical Sagittal parameters on pre-operative disability in patients indicated for surgery. METHODS Patients with pre-operative standing cervical radiographs, no prior cervical spine procedures and a pre-operative NDI score were identified. Measurements were made by two observers at two different time points. Parameters measured were: Occiput-C2 angle, C1-C2 angle, C2-C7 angle (CL), T1 slope (TS), TS minus CL (TS-CL), C2-C7 SVA, and C1-C7 SVA. Intra- and inter-observer reliability was calculated. Subgroup analyses of myelopathy vs. radiculopathy and deformity vs. no deformity was performed. A multivariate linear regression was performed. RESULTS Ninety patients were included. Indications included cervical myelopathy (n = 63), cervical radiculopathy (n = 25), cervical stenosis (n = 9), and others (n = 5). CL averaged -13.7 ± 14.9 degrees. TS averaged 30.7 ± 10.4 degrees and C2-C7 SVA averaged 28.8 ± 13.2 mm. Intra- and inter-observer reliability was good to excellent (ICC > 0.8). Increasing CL (r = 0.277, P = 0.009), increasing TS (r = -0.273, P = 0.011) and increasing TS-CL (r = -0.301, P = 0.005) were correlated with decreasing NDI. CL, TS and TS-CL were also strongly correlated with each other (r > 0.65, P < 0.001 for all bivariate correlations). A multivariate regression adjusting for age and indication showed TS-CL (P = 0.040) and C2-C7 SVA (P = 0.015) were independent predictors of NDI. CONCLUSION Increasing CL, increasing TS and increasing TS-CL are correlated with decreasing pre-operative NDI. Low TS-CL and high C2-C7 SVA are independent predictors of high pre-operative NDI. LEVEL OF EVIDENCE 4.
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the impact of standing regional cervical Sagittal Alignment on outcomes in posterior cervical fusion surgery
The Spine Journal, 2012Co-Authors: Jessica A Tang, Frank J Schwab, Virginie Lafage, Justin K Scheer, Robert A Hart, Vedat Deviren, Justin S Smith, Shay Bess, Christopher I Shaffrey, Christopher P AmesAbstract:Background Positive spinal regional and global Sagittal malAlignment has been repeatedly shown to correlate with pain and disability in thoracolumbar fusion. Objective To evaluate the relationship between regional cervical Sagittal Alignment and postoperative outcomes for patients receiving multilevel cervical posterior fusion. Methods From 2006 to 2010, 113 patients received multilevel posterior cervical fusion for cervical stenosis, myelopathy, and kyphosis. Radiographic measurements made at intermediate follow-up included the following: (1) C1-C2 lordosis, (2) C2-C7 lordosis, (3) C2-C7 Sagittal vertical axis (C2-C7 SVA; distance between C2 plumb line and C7), (4) center of gravity of head SVA (CGH-C7 SVA), and (5) C1-C7 SVA. Health-related quality-of-life measures included neck disability index (NDI), visual analog pain scale, and SF-36 physical component scores. Pearson product-moment correlation coefficients were calculated between pairs of radiographic measures and health-related quality-of-life scores. Results Both C2-C7 SVA and CGH-C7 SVA negatively correlated with SF-36 physical component scores (r =-0.43, P Conclusion Our findings demonstrate that, similar to the thoracolumbar spine, the severity of disability increases with positive Sagittal malAlignment following surgical reconstruction.
Jeanmarc Macthiong - One of the best experts on this subject based on the ideXlab platform.
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global Sagittal Alignment and health related quality of life in lumbosacral spondylolisthesis
European Spine Journal, 2013Co-Authors: Adil Harroud, Jeanmarc Macthiong, Hubert Labelle, Julie JoncasAbstract:Purpose Global Sagittal Alignment is considered as an important aspect in the management of spinal disorders, but the evidence establishing its clinical impact in lumbosacral spondylolisthesis is still poor. This study evaluated the impact of global Sagittal Alignment on the health-related quality of life (HRQOL) of patients with spondylolisthesis.
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pediatric Sagittal Alignment
European Spine Journal, 2011Co-Authors: Jeanmarc Macthiong, Hubert Labelle, Pierre RoussoulyAbstract:There is a wide variation in the regional parameters used to describe the spine and sacro-pelvis in children and adolescents. There is a slight tendency for thoracic kyphosis and lumbar lordosis to increase with age. Pelvic incidence and pelvic tilt also tend to increase during growth, while sacral slope remains relatively stable. Strong knowledge of the close relationships between adjacent anatomical regions of the spine and sacro-pelvis is the key when evaluating and interpreting Sagittal spino-pelvic Alignment. The scheme of correlations between adjacent regional parameters needs to be preserved in order to maintain a balanced posture. The net resultant from these relationships between adjacent anatomical regions is best represented by parameters of Sagittal global balance. C7 plumbline tends to move backwards from childhood to adulthood, where it stabilizes or slightly moves forward secondary to degenerative changes. C7 plumbline in front of both hip axis and center of the upper sacral endplate occurs in 29% of subjects aged 3–10 years, 12% of subjects aged between 10 and 18 years, and 14% of subjects aged 18 years or older. Therefore, although most normal subjects stand with a C7 plumbline behind the hip axis, a C7 plumbline in front of both hip axis and sacrum can be seen in normal individuals. However, progressive forward displacement of C7 plumbline should raise a suspicion for the risk of developing spinal pathology.
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Sagittal Alignment of the spine and pelvis during growth
Spine, 2004Co-Authors: Jeanmarc Macthiong, Eric Berthonnaud, John R Dimar, Randal R Betz, H LabelleAbstract:STUDY DESIGN Prospective study of the Sagittal plane Alignment of the spine and pelvis in the normal pediatric population. OBJECTIVES To document the Sagittal Alignment of the spine and pelvis and its change during growth in the normal pediatric population. SUMMARY OF BACKGROUND DATA Pelvic morphology as well as Sagittal Alignment of the spine and pelvis in the pediatric population are poorly defined in the literature. METHODS Five parameters were evaluated on lateral standing radiographs of 180 normal study participants 4 to 18 years of age: thoracic kyphosis, lumbar lordosis, sacral slope, pelvic tilt, and pelvic incidence. Statistical analysis was performed using two-tailed Student t tests and Pearson's coefficients (level of significance = 0.01). RESULTS The mean thoracic kyphosis, lumbar lordosis, sacral slope, pelvic tilt, and pelvic incidence values were 43.0 degrees, 48.5 degrees, 41.2 degrees, 7.2 degrees and 48.4 degrees, respectively. There was no significant difference between males and females. Thoracic kyphosis, lumbar lordosis, pelvic tilt, and pelvic incidence were found to be weakly correlated with age, while sacral slope remained stable with growth. CONCLUSIONS Pelvic morphology, as measured by the pelvic incidence angle, tends to increase during childhood and adolescence before stabilizing into adulthood, most likely to maintain an adequate Sagittal balance in view of the physiologic and morphologic changes occurring during growth. Pelvic tilt and lumbar lordosis, two position-dependent parameters, also react by increasing with age, most likely to avoid inadequate anterior displacement of the body center of gravity. Sacral slope is achieved with the standing posture and is not further significantly influenced by age. These results are important to establish baseline values for these measurements in the pediatric population, in view of the reported association between pelvic morphology and the development of various spinal disorders such as spondylolisthesis and scoliosis.
Daniel K Riew - One of the best experts on this subject based on the ideXlab platform.
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correlation and reliability of cervical Sagittal Alignment parameters between lateral cervical radiograph and lateral whole body eos stereoradiograph
Global Spine Journal, 2016Co-Authors: Weerasak Singhatanadgige, Daniel G Kang, Panya Luksanapruksa, Colleen Peters, Daniel K RiewAbstract:Study Design Retrospective analysis. Objective To evaluate the correlation and reliability of cervical Sagittal Alignment parameters obtained from lateral cervical radiographs (XRs) compared with lateral whole-body stereoradiographs (SRs). Methods We evaluated adults with cervical deformity using both lateral XRs and lateral SRs obtained within 1 week of each other between 2010 and 2014. XR and SR images were measured by two independent spine surgeons using the following Sagittal Alignment parameters: C2–C7 Sagittal Cobb angle (SCA), C2–C7 Sagittal vertical axis (SVA), C1–C7 translational distance (C1–7), T1 slope (T1-S), neck tilt (NT), and thoracic inlet angle (TIA). Pearson correlation and paired t test were used for statistical analysis, with intra- and interrater reliability analyzed using intraclass correlation coefficient (ICC). Results A total of 35 patients were included in the study. We found excellent intrarater reliability for all Sagittal Alignment parameters in both the XR and SR groups with ICC ranging from 0.799 to 0.994 for XR and 0.791 to 0.995 for SR. Interrater reliability was also excellent for all parameters except NT and TIA, which had fair reliability. We also found excellent correlations between XR and SR measurements for most Sagittal Alignment parameters; SCA, SVA, and C1–C7 had r > 0.90, and only NT had r p p Conclusion Whole-body stereoradiography appears to be a viable alternative for measuring cervical Sagittal Alignment parameters compared with standard radiography. XR and SR demonstrated excellent correlation for most Sagittal Alignment parameters except NT. However, SR had significantly lower average SVA and C1–C7 measurements than XR. The lower radiation exposure using single SR has to be weighed against its higher cost compared with XR.
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does whole spine lateral radiograph with clavicle positioning reflect the correct cervical Sagittal Alignment
European Spine Journal, 2015Co-Authors: Sangmin Park, Kwang Sup Song, Seung Hwan Park, Hyun Kang, Daniel K RiewAbstract:To evaluate the differences of cervical Alignment between standing cervical lateral radiograph and whole-spine lateral radiograph with clavicle position. We prospectively evaluated 101 asymptomatic adults from whom standing cervical lateral radiograph with hands on both side followed by whole-spine lateral radiographs with clavicle position were obtained from April 2012 to December 2013. On two radiographs, cervical Sagittal Alignment from C2 to C7 was analyzed by Gore angle (GA) and Cobb angle (CA); head position was evaluated using the translation distance (TD, distance of the anterior tubercle of C1 compared with the vertical line through the posterior-inferior body of C7) and McGregor angle (MA, angle between the McGregor and horizontal lines). T1-slope was also evaluated. Cervical Alignment on the cervical radiograph (GA −13.59° [−15.58 to −11.60], CA −9.76° [−11.65 to −7.86]) was significantly more lordotic than that on whole-spine radiographs (GA −6.28° [−8.65 to −3.91] and −4.14° [−6.40 to −1.89]). TD and MA on cervical radiographs (TD 34.98 mm [33.22–36.75]; MA 7.20° [6.35–8.35]) were meaningfully higher than those on whole-spine radiographs (TD 31.31 mm [29.47–33.16]; MA 6.32° [5.25–7.39]), but the MA values were not significant (p = 0.064). T1-slope was significantly lower in whole-spine radiographs (20.11° [18.88–21.35]) than in cervical radiographs (24.37° [23.14–25.6]). Values are expressed as mean (95 % confidence interval). Clavicle position during whole-spine radiograph caused a substantial decrease in the T1-slope; head position posteriorly translated followed by the cervical Sagittal Alignment became more hypo-lordotic, with slight downward gazing in comparison with the cervical radiograph.
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Sagittal Alignment as a predictor of clinical adjacent segment pathology requiring surgery after anterior cervical arthrodesis
The Spine Journal, 2014Co-Authors: Moon Soo Park, Michael P Kelly, Dong Ho Lee, Wookie Min, Rakerry K Rahman, Daniel K RiewAbstract:Abstract Background context Postoperative malAlignment of the cervical spine may alter cervical spine mechanics and put patients at risk for clinical adjacent segment pathology requiring surgery. Purpose To investigate whether a relationship exists between cervical spine Sagittal Alignment and clinical adjacent segment pathology requiring surgery (CASP-S) following anterior cervical fusion (ACF). Study design Retrospective matched study. Patient sample A total of 122 patients undergoing ACF between 1996 and 2008 were identified, with a minimum of 2 years of follow-up. Outcome measures Radiographs were reviewed to measure the Sagittal Alignment using C2 and C7 Sagittal plumb lines, distance from the fusion mass plumb line to the C2 and C7 plumb lines, the Alignment of the fusion mass, caudally adjacent disc angle, the Sagittal slope angle of the superior end plate of the vertebra caudally adjacent to the fusion mass, T1 Sagittal angle, overall cervical Sagittal Alignment, and curve patterns by Katsuura classification. Methods A total of 122 patients undergoing ACF between 1996 and 2008 were identified, with a minimum of 1 year of follow-up. Patients were divided into groups according to the development of CASP (control/CASP-S) and by number/location of levels fused. Radiographs were reviewed to measure the Sagittal Alignment using C2 and C7 Sagittal plumb lines, distance from the fusion mass plumb line to the C2 and C7 plumb lines, the Alignment of the fusion mass, caudally adjacent disc angle, the Sagittal slope angle of the superior end plate of the vertebra caudally adjacent to the fusion mass, T1 Sagittal angle, overall cervical Sagittal Alignment, and curve patterns by Katsuura classification. Appropriate statistical tests were performed to calculate relationships between the variables and the development of CASP-S. No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this article. Results The groups were similar with regard to demographic and surgical variables. Lordosis was preserved in 82% (50/61) of the control group but in only 66% (40/61) of the CASP-S group (p=.033). More patients with a straight curve pattern developed CASP-S. The distance from the C2 to the C7 plumb line and T1 Sagittal slope angle were lower in the CASP-S group with C5–C6 fusions compared with the control group. Also, the distance from C5–C6 fusion mass to C7 plumb line and C7 Sagittal slope angle were lower in the CASP-S group with C5–C6 fusions. Conclusions Our results suggest that malAlignment of the cervical spine following an ACF at C5–C6 has an effect on the development of clinical adjacent segment pathology requiring surgery.
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the effect of age on cervical Sagittal Alignment normative data on 100 asymptomatic subjects
Spine, 2013Co-Authors: Moon Soo Park, Seok-woo Kim, Tae Hwan Kim, Seonghwan Moon, Hwan Mo Lee, Seung Yeop Lee, Daniel K RiewAbstract:STUDY DESIGN Retrospective study. OBJECTIVE To determine age-related changes in cervical Sagittal Alignment using whole-spine standing radiographs in asymptomatic adults. SUMMARY OF BACKGROUND DATA Modern surgical techniques have emphasized the importance of maintaining proper Sagittal Alignment. But there is a paucity of literature investigating age-related changes in cervical Sagittal Alignment. METHODS One hundred healthy unoperated adults who were free of spinal problems obtained whole-spine standing radiographs. They consisted of 2 groups divided by age: those in their 20s and those older than 60 years. Each group had an equal ratio of males and females. Distances from C2 as well as C7 plumb lines to the following points were measured: thoracic and lumbar apex as well as the posterior superior corner of the S1 vertebral body. In addition, Cobb angles for C0-C2, C2-C7, thoracic kyphotic angle, lumbar lordotic angle, and T1 Sagittal slope angles were measured. RESULTS The distance between the C2 and C7 plumb lines did not vary with age. The thoracic apex shifted caudally from T6 in the younger group to T7 in the older group. The most common lumbar apex was L4 for both groups. The distance from C2, as well as C7 plumb lines to the posterior superior corner of the S1 vertebral body, as well as the thoracic apex increased significantly in the older group. On the contrary, the distance from the 2 plumb lines to the lumbar apex decreased in the older group. Also, C2-C7 angle increased and T1 Sagittal slope angle decreased in the older group compared with the younger group. However, no difference was found for the other Cobb angles between the 2 groups. CONCLUSION The distances between the plumb lines from C2 and C7 were maintained but C2-C7 Sagittal angle increased with aging.
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comparison of anterior cervical fusion after two level discectomy or single level corpectomy Sagittal Alignment cervical lordosis graft collapse and adjacent level ossification
The Spine Journal, 2009Co-Authors: Yung Park, Takeshi Maeda, Daniel K RiewAbstract:Abstract Background context Single-level corpectomy and two-level discectomy with anterior cervical plating have been reported to have comparable fusion and complication rates. However, there are few large series that have compared the two for Sagittal Alignment, cervical lordosis, graft subsidence, and adjacent-level ossification. Purpose To determine the differences between these two procedures for patients with two-level spondylosis by comparing the pre- and postoperative radiographic data. Study design Retrospective review of prospectively collected data in an academic institution. Patient sample Fifty-two with a single-level corpectomy and 45 with a two-level anterior cervical discectomy and fusion (ACDF). Outcome measures Pre- and postoperative radiographic data for Sagittal Alignment, cervical lordosis, subsidence, and adjacent-level ossification. Methods We retrospectively reviewed the lateral cervical radiographs of patients who had a solid fusion after a single-level cervical corpectomy or a two-level ACDF for the treatment of a degenerative cervical spondylosis by a surgeon at an academic institution. The choice of the operation was dependent on the presence or absence of retrovertebral compression. All patients underwent anterior cervical fusion using fibula strut allograft and variable-angle screw-plate fixation. None had had prior cervical spine surgery. Twenty-five were excluded because of inadequate radiographs and follow-up. There were 52 with a single-level corpectomy and 45 with a two-level ACDF. The following were analyzed: 1) Sagittal Alignment (modified method of Toyama); 2) cervical lordosis measured by Cobb angles of fusion constructs (fusion Cobb) and C2–C7 (C2–C7 Cobb); 3) graft collapse determined by the subsidence of anterior/posterior body height of fused segments (anterior/posterior subsidence) and the cranial/caudal plate-to-disc distances (cranial/caudal subsidence), and the difference between anterior and posterior body height for the fused levels (anteroposterior [AP] difference); and 4) the severity of ossification at two adjacent levels. Results The mean durations of follow-up were 23.3±6.6 (corpectomy) and 25.7±6.2 (ACDF) months, range 12 to 45 months. There were no significant differences between the two groups in Sagittal Alignment, cervical lordosis, graft collapse, and adjacent-level ossification. Graft subsidence and loss of cervical lordosis occurred significantly more during the first 6 weeks after surgery (all measurements, p Conclusions Our data suggest that the two procedures yield comparable results in terms of Sagittal Alignment, cervical lordosis, graft subsidence, and adjacent-level ossification. Graft subsidence and loss of cervical lordosis appeared to occur mainly during the first 6 weeks after surgery. Single-level corpectomy and fusion continued to subside at the posterior portion of caudal end plate even after 6 weeks. On the other hand, graft subsidence did not correlate with preoperative and final postoperative Sagittal Alignments.
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effective prevention of proximal junctional failure in adult spinal deformity surgery requires a combination of surgical implant prophylaxis and avoidance of Sagittal Alignment overcorrection
Spine, 2020Co-Authors: Breton Line, Renaud Lafage, Frank J Schwab, Han Jo Kim, Munish C Gupta, Shay Bess, V Lafage, Christopher P Ames, Michael J Kelly, Douglas BurtonAbstract:STUDY DESIGN Propensity score matched analysis of a multi-center prospective adult spinal deformity (ASD) database. OBJECTIVE Evaluate if surgical implant prophylaxis combined with avoidance of Sagittal overcorrection more effectively prevents proximal junctional failure (PJF) than use of surgical implants alone. SUMMARY OF BACKGROUND DATA PJF is a severe form of proximal junctional kyphosis (PJK). Efforts to prevent PJF have focused on use of surgical implants. Less information exists on avoidance of overcorrection of age-adjusted Sagittal Alignment to prevent PJF. METHODS Surgically treated ASD patients (age ≥18 yrs; ≥5 levels fused, ≥1 year follow-up) enrolled into a prospective multi-center ASD database were propensity score matched (PSM) to control for risk factors for PJF. Patients evaluated for use of surgical implants to prevent PJF (IMPLANT) versus no implant prophylaxis (NONE), and categorized by the type of implant used (CEMENT, HOOK, TETHER). Postoperative Sagittal Alignment was evaluated for overcorrection of age-adjusted Sagittal Alignment (OVER) versus within Sagittal parameters (ALIGN). Incidence of PJF was evaluated at minimum 1 year postop. RESULTS Six hundred twenty five of 834 eligible for study inclusion were evaluated. Following PSM to control for confounding variables, analysis demonstrated the incidence of PJF was lower for IMPLANT (n = 235; 10.6%) versus NONE (n = 390: 20.3%; P < 0.05). Use of transverse process hooks at the upper instrumented vertebra (HOOK; n = 115) had the lowest rate of PJF (7.0%) versus NONE (20.3%; P < 0.05). ALIGN (n = 246) had lower incidence of PJF than OVER (n = 379; 12.0% vs. 19.2%, respectively; P < 0.05). The combination of ALIGN-IMPLANT further reduced PJF rates (n = 81; 9.9%), while OVER-NONE had the highest rate of PJF (n = 225; 24.2%; P < 0.05). CONCLUSION Propensity score matched analysis of 625 ASD patients demonstrated use of surgical implants alone to prevent PJF was less effective than combining implants with avoidance of Sagittal overcorrection. Patients that received no PJF implant prophylaxis and had Sagittal overcorrection had the highest incidence of PJF. LEVEL OF EVIDENCE 3.
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effective prevention of proximal junctional failure in adult spinal deformity surgery requires a combination of surgical implant prophylaxis and avoidance of Sagittal Alignment overcorrection
Spine, 2020Co-Authors: Breton Line, Michael P Kelly, Renaud Lafage, Frank J Schwab, Munish C Gupta, Shay Bess, V Lafage, Christopher P Ames, Douglas Burton, Robert HartAbstract:STUDY DESIGN: Propensity score matched analysis of a multi-center prospective adult spinal deformity (ASD) database. OBJECTIVE: Evaluate if surgical implant prophylaxis combined with avoidance of Sagittal overcorrection more effectively prevents proximal junctional failure (PJF) than use of surgical implants alone. SUMMARY OF BACKGROUND DATA: PJF is a severe form of proximal junctional kyphosis (PJK). Efforts to prevent PJF have focused on use of surgical implants. Less information exists on avoidance of overcorrection of age-adjusted Sagittal Alignment to prevent PJF. METHODS: Surgically treated ASD patients (age ≥18 years; ≥5 levels fused, ≥1 year follow-up) enrolled into a prospective multi-center ASD database were propensity score matched (PSM) to control for risk factors for PJF. Patients evaluated for use of surgical implants to prevent PJF (IMPLANT) vs. no implant prophylaxis (NONE), and categorized by the type of implant used (CEMENT, HOOK, TETHER). Postoperative Sagittal Alignment was evaluated for overcorrection of age-adjusted Sagittal Alignment (OVER) vs. within Sagittal parameters (ALIGN). Incidence of PJF was evaluated at minimum 1 year postop. RESULTS: 625 of 834 eligible for study inclusion were evaluated. Following PSM to control for confounding variables, analysis demonstrated the incidence of PJF was lower for IMPLANT (n = 235; 10.6%) vs. NONE (n = 390: 20.3%; p < 0.05). Use of transverse process hooks at the upper instrumented vertebra (HOOK; n = 115) had the lowest rate of PJF (7.0%) vs. NONE (20.3%; p < 0.05). ALIGN (n = 246) had lower incidence of PJF than OVER (n = 379; 12.0% vs. 19.2%, respectively; p < 0.05). The combination of ALIGN-IMPLANT further reduced PJF rates (n = 81; 9.9%), while OVER-NONE had the highest rate of PJF (n = 225; 24.2%; p < 0.05). CONCLUSION: Propensity score matched analysis of 625 ASD patients demonstrated use of surgical implants alone to prevent PJF was less effective than combining implants with avoidance of Sagittal overcorrection. Patients that received no PJF implant prophylaxis and had Sagittal overcorrection had the highest incidence of PJF. LEVEL OF EVIDENCE: 3.
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thoracolumbar junction orientation its impact on thoracic kyphosis and Sagittal Alignment in both asymptomatic volunteers and symptomatic patients
European Spine Journal, 2019Co-Authors: Hong Joo Moon, Keith H Bridwell, Alekos A Theologis, Micheal P Kelly, Thamrong Lertudomphonwanit, Han Jo Kim, Lawrence G Lenke, Munish C GuptaAbstract:The thoracolumbar junction (TLJ) has not been explored in regard to its contribution to global Sagittal Alignment. This study aims to define novel Sagittal parameters of the TLJ and to assess their roles within global Sagittal Alignment. Included for cross-sectional, retrospective analysis were asymptomatic volunteers and symptomatic patients who had undergone operation for adult spinal deformity. Unique Sagittal parameters of the TLJ were measured using the midline of the T12–L1 disk space: The TLJ orientation [TLJO; thoracolumbar tilt (TLT) and slope (TLS)]. Thoracic kyphosis (TK; T5–12), C7–S1 Sagittal vertical axis (SVA), lumbar lordosis (LL; L1–S1), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI) were measured. Continuous variables were compared using the independent t test. Pearson correlations examined relationships between the parameters in each group. The asymptomatic TK was calculated using the measurement of the asymptomatic volunteer’s TLJO by linear regression. One hundred fifteen asymptomatic volunteers and 127 symptomatic patients were included. Only LL among the lumbopelvic parameters correlated with TK (asymptomatic volunteers: r = − 0.42; symptomatic patients: r = − 0.40). All the pelvic parameters have no direct correlation with TK in both groups. TLJO had stronger correlation with TK [asymptomatic volunteers: r = − 0.68 (TLS), r = 0.41 (TLT); symptomatic patients: r = − 0.56 (TLS), r = 0.44 (TLT)] than the lumbopelvic parameters. TLS correlated with LL (asymptomatic volunteers: r = 0.78; symptomatic patients: r = 0.73). Most pelvic parameters correlated with TLJO except for PI. The asymptomatic TK was estimated by the derived formula: 20.847 + TLS × (− 1.198). The TLJO integrates the status of the lumbopelvic Sagittal parameters and simultaneously correlates with thoracic and global Sagittal Alignment. These slides can be retrieved under Electronic Supplementary Material.
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Sagittal Alignment and complications following lumbar 3 column osteotomy does the level of resection matter
Journal of Neurosurgery, 2017Co-Authors: Emmanuelle Ferrero, Munish C Gupta, Gregory M Mundis, Christopher P Ames, Barthelemy Liabaud, Jensen K Henry, Khaled M Kebaish, Richard A Hostin, Oheneba Boachieadjei, Justin S SmithAbstract:OBJECTIVEThree-column osteotomy (3CO) is a demanding technique that is performed to correct Sagittal spinal malAlignment. However, the impact of the 3CO level on pelvic or truncal Sagittal correction remains unclear. In this study, the authors assessed the impact of 3CO level and postoperative apex of lumbar lordosis on Sagittal Alignment correction, complications, and revisions.METHODSIn this retrospective study of a multicenter spinal deformity database, radiographic data were analyzed at baseline and at 1- and 2-year follow-up to quantify spinopelvic Alignment, apex of lordosis, and resection angle. The impact of 3CO level and apex level of lumbar lordosis on the Sagittal correction was assessed. Logistic regression analyses were performed, controlling for cofounders, to investigate the effects of 3CO level and apex level on intraoperative and postoperative complications as well as on the need for subsequent revision surgery.RESULTSA total of 468 patients were included (mean age 60.8 years, mean body m...
