Quantitative assessment of muscle activity of back and lower extremities, whole body sagittal alignment, body sway, and health-related quality of life in adult spinal deformity patients before and after spinopelvic correction surgery: From the standpoint of the "cone of economy".

BACKGROUND AND AIMS: Pain and muscle fatigue in the low back and lower extremity associated with adult spinal deformity (ASD) markedly limit daily activities and affect quality of life. This study aimed to clarify if spinal correction surgery decreases the muscle activity requirements in relation to alignment and balance parameters. METHODS: Integrated electromyogram (I-EMG) studies of the low back and lower extremity in addition to whole body alignment, body sway, and health-related quality of life (HRQOL) were evaluated in 16 patients with ASD before and after surgery. Sixteen healthy volunteers were included as control subjects. Muscle activities of the bilateral lumbar paravertebral, biceps femoris, rectus femoris, gastrocnemius, and tibialis anterior were measured using surface electromyogram in both resting and working standing positions. Surgical outcomes were based on improvements in muscle fatigue using the sum of the whole muscle I-EMGs and body sway. HRQOL was evaluated by SRS-22r, which measures 4 domains (function, pain, self-image, mental health) and subtotal scores. RESULTS: In controls, the sum of the 10 whole I-EMGs (mVms; mean ± SD) was 3316 ± 1247 in the resting standing position and 5625 ± 2065 in the working standing position. The I-EMG values were higher in ASD patients than in healthy subjects; in the resting standing position, the sum of the whole 10 I-EMGs significantly decreased from baseline (9125 ± 3529) to 3 (6088 ± 1793) and 6 (6381 ± 1776) months postoperatively (p < 0.01). In the working standing position, the sum in ASD patients also significantly decreased from baseline (14,160 ± 5474) to 3 (8085 ± 2540) and 6 (8557 ± 3025) months postoperatively (p < 0.01). I-EMG values did not differ significantly between the 3- and 6-month time points in either condition. Body sway was also improved postoperatively at 3 months and maintained at 6 months along with the amelioration of whole-body sagittal alignment, and 4 domains and subtotal SRS-22r scores significantly increased postoperatively. CONCLUSION: Following spinopelvic correction surgery, whole body sagittal alignment was improved, and muscle activity based on I-EMG and body sway were significantly decreased. The SRS-22r scores after surgery also indicated significant improvement, suggesting that muscle fatigue in the standing position was ameliorated, i.e., the "cone of economy" was normalized.

Anatomical Pelvic Parameters Using the Anterior Pelvic Plane: Normative Values and Estimation of the Standing Sagittal Alignment in Healthy Volunteers.

Introduction: In this study, we aim to estimate the natural standing sagittal alignment in patients with adult spinal deformity (ASD), firstly by investigating the normative values of anatomical pelvic parameters based on the anterior pelvic plane (APP) in a healthy population, and to clarify the relationships between the anatomical and positional pelvic parameters in standing position. Methods: The images of biplanar slot-scanning full-body stereoradiography in 140 healthy Japanese volunteers (mean age, 39.5 years; 59.3% female) were examined. In addition to three-dimensional measurements including pelvic incidence (PI), sacral slope (SS), and pelvic tilt (PT), the APP angle (APPA; anterior tilting=positive) was measured as the angle between the APP and the vertical line using the two-dimensional lateral image. Anatomical SS and PT (aSS and aPT) were calculated as the angles of SS and PT in reference to APP. Results: The mean (range) values of APPA, aSS, and aPT were determined to be 0.7° (-16.8°/15.5°), 36.8° (18.3°/64.9°), and 13.2° (-0.6°/28.7°), respectively. Moreover, SS was found to be significantly correlated with PI and aSS, while PT was significantly correlated with PI, aSS, aPT, and body weight. Also, PT was significantly larger in females than in males. Multiple linear regression analysis deduced the following equations: SS=0.404×aSS+0.203×PI+12.463, PT=-0.391×aSS+0.774×PI+1.950×sex (male=0, female=1)-12.971, wherein aSS had the greatest effect for predicting SS among the included factors and PI had the greatest effect for predicting PT. In addition, no significant differences were noted between PT/PI and aPT/PI. Conclusions: As per the results of this study, significant correlations were noted among parameters and predicting models for positional parameters (SS and PT) using anatomical parameters (aSS and aPT) in a healthy population. This novel measurement concept based on the APP has been considered to be useful in estimating natural SS and PT in standing position using the anatomical pelvic parameters in patients with ASD.

Racial differences in whole-body sagittal alignment between Asians and Caucasians based on international multicenter data.

PURPOSE: To examine inherent differences adjusted for age and clinical score in whole-body sagittal (WBS) alignment involving the lower extremities between Asians and Caucasians, and to determine the relationship between age and WBS parameters by race and sex. METHODS: A total of 317 individuals consisting of 206 Asians and 111 Caucasians participated. WBS parameters including C2-7 lordotic angle, lower lumbar lordosis (lower LL, L4-S), pelvic incidence (PI), pelvic thickness, knee flexion (KF), sagittal vertical axis (SVA), and T1 pelvic angle (TPA) were evaluated radiologically. Propensity score-matching adjustments for age and the Oswestry Disability Index scores for comparative analysis between the two race cohorts and correlation analysis between age and WBS parameters for all subjects by race and sex were conducted. RESULTS: The comparative analysis included 136 subjects (age: Asians 41.1 ± 13.5, Caucasians 42.3 ± 16.2 years, p = 0.936). Racial differences in WBS parameters were observed in C2-7 lordotic angle (-1.8 ± 12.3 vs. 6.3 ± 12.2 degrees, p = 0.001), and lower LL (34.0 ± 6.6 vs. 38.0 ± 6.1 degrees, p < .001). In correlation analysis with age, moderate or more significant correlations with age were found in KF for all groups, and in SVA and TPA for females of both racial groups. Age-related changes in pelvic parameters of PI and pelvic thickness were more significant in Caucasian females. CONCLUSION: Analysis of the correlation between age and WBS parameters suggested that age-related WBS changes vary between races and should be considered during corrective spinal surgery.

The age-specific normative values of standing whole-body sagittal alignment parameters in healthy adults: based on international multicenter data.

PURPOSE: To investigate the age-specific normative values of whole-body sagittal alignment (WBSA) including global balance parameters in healthy adults and to clarify the correlations among parameters based on the data from three international multicenter. METHODS: Three hundred and seventeen healthy subjects (range: 20-84 y.o., mean: 43.8 ± 14.7 y.o.) were included and underwent whole-body biplanar X-ray imaging system. Spinopelvic parameters and knee flexion (KF), the center of acoustic meatus (CAM)-hip axis (HA), and C2 dentiform apophyse (OD)-HA, the cranial center (Cr)-HA were evaluated radiologically. Sub-analysis for correlation analysis between age and parameters and among parameters was performed to investigate age-specific change and compensatory mechanisms. RESULTS: For age-related change, C2-7 angle (r = .326 for male/.355 for female), KF (r = .427/.429), and SVA (r = .234/.507) increased with age in both male and female group. For global parameters related to the center of the gravity, correlations with age were not significant (r = .120/.161 for OD-HA, r = .163/.275 for Cr-HA, r = .149/.262 for CAM-HA). Knee flexion (KF) has correlation with global parameters (i.e., SVA, OD-HA, Cr-HA, CAM-HA) and does not have correlations with local spinopelvic alignment. CONCLUSION: While several local alignment changes with age were found, changes in global parameters related to the center of gravity were kept relatively mild by the chain of compensation mechanisms including the lower limbs. We showed the normative values for a comprehensive WBSA in standing posture from large international healthy subjects' database.

Scoliosis Research Society-22r score is affected by standing whole body sagittal alignment, age, and sex, but not by standing balance or skeletal muscle mass in healthy volunteers.

PURPOSE: Aging and spinal disease impair standing whole body sagittal alignment (WBS alignment), which leads to stooping. When WBS alignment deteriorates, compensatory mechanisms are activated to maintain standing posture. Increase of the compensation impairs health-related quality of life (HRQOL). The purpose of this research was to determine whether postural factors, age, and sex affect HRQOL. METHODS: This cross-sectional study evaluated the influence of WBS alignment, standing body sway (balance), skeletal muscle mass (SMM), aging, and sex on HRQOL in healthy volunteers (n = 150; mean age 40.9 years [20-76], 96 women). Age, sex, weight, height, and body mass index (BMI) were obtained. HRQOL was assessed with Scoliosis Research Society-22 (SRS-22r). WBS alignment and balance were measured by EOS imaging with simultaneous force plate measurement. SMM was measured using a medical body composition analyzer. Based on the bivariate analysis between the SRS-22r subtotal and all parameters, selected ten parameters were used for multivariate logistic regression analysis to identify affecting factors to SRS-22r. RESULTS: Men had significantly higher weight, height, BMI, and SRS-22r score in all domains. The L4-S1 lumbar lordosis angle was greater in men, and pelvic tilt and knee hyperextension were greater in women. Women had a more stable standing posture, whereas men had significantly higher SMM values. Multivariate logistic regression analysis revealed that age, sex, and TPA were identified as significant factors affecting SRS-22r. CONCLUSIONS: In healthy volunteers, SRS-22r is affected by aging, sex (woman had a lower score), and sagittal malalignment. Neither Standing balance nor SMM, however, affect SRS-22r.4.

Pelvic thickness, sex, ethnicity, and age affect pelvic incidence in healthy volunteers of Multi-Ethnic Alignment Normative Study (MEANS) database.

BACKGROUND: The purpose of this study was to investigate the affecting factors on pelvic incidence (PI) and to test the hypothesis that PI changes even after skeletal maturity probably due to hypermobility of the sacroiliac joint using a large international multi-center database. METHODS: A prospective and cross-sectional healthy adult volunteers, ages 18-80 years, across 5 countries were used. Radiographic measurements included standard whole body alignment parameters. Bivariate regression analyses between PI versus demographics and spino-pelvic anatomical parameters were performed. An effect of sex on pelvic anatomical parameters was also investigated. Multivariate logistic regression with a forward stepwise procedure was performed to identify the contributing factors to PI, and an appropriate model was obtained. RESULTS: PI showed a significant positive correlation with age in pooled data. Divided by sex, however, there was no correlation in men, but women showed a significant higher correlation coefficient. Pelvic thickness (PTh) had a significant negative correlation with age in pooled data. Divided by sex, no correlation was found in men, but there was a significant correlation in women with higher correlation coefficient. The stepwise multivariate analysis for the factors on PI identified four significant factors: age, sex, ethnicity, and PTh. CONCLUSIONS: PTh, sex, ethnicity, and age affected PI. There was a positive correlation between PI and age. The tendency was more significant in woman than in man. The results support the hypothesis that PI increases with aging, but the change seems to be small and needs to be verified in a longitudinal evaluation.

Influence of lumbosacral transitional vertebrae on spinopelvic parameters using biplanar slot scanning full body stereoradiography-analysis of 291 healthy volunteers.

BACKGROUND: Proper identification of lumbosacral transitional vertebrae (LSTV) is important to characterize the relationship between the transitional segment and adjacent levels. Classical classification schemes are inaccurate with respect to the whole spine. We propose a precise vertebral numbering method and investigated the relationship between LSTV and whole-body sagittal alignment. METHODS: A total of 291 healthy adult volunteers with no history of spinal disease were evaluated with biplanar slot scanning full body stereoradiography to determine the prevalence of LSTV. Vertebrae were counted from the first cervical vertebra using both coronal and sagittal plane images. We then investigated the influence of LSTV on whole-body sagittal alignment in 279 participants. Whole-body key parameters descriptive statistics were compared among groups according to the number of vertebrae (L4, L5, and L6). Statistical analysis was performed between normal and LSTV cases using the Steel-Dwass analysis. RESULTS: Of the 291 subjects, 14 (4.8%) had 23 vertebrae and 16 (5.5%) had 25 vertebrae. Eleven (3.8%) had Th11, 3 (1.0%) had L4, and 1 (0.3%) had Th11 + L6, 16 (5.5%) had L6. Compared with the normal group, the sacral base in relation to the pelvis was higher in the L4 group and lower in the L6 group. The C2-C7 angle and lumbar lordosis (LL) were increased in both the L4 and L6 groups. All remaining parameters were decreased in the L4 group and increased in the L6 group. The relationship between LL and PI was similar in the normal and LSTV groups, despite the difference in the sacral base location. CONCLUSIONS: We propose a precise method for numbering the vertebrae using coronal and sagittal full body images. The spinopelvic parameters of the LSTV population significantly differed from those in the normal spine population due to differences in the sacral base location.

Sacral incidence to pubis: a novel and alternative morphologic radiological parameter to pelvic incidence in assessing spinopelvic sagittal alignment.

BACKGROUND: Although pelvic incidence (PI) is a key morphologic parameter in assessing spinopelvic sagittal alignment, accurate measurements of PI become difficult in patients with severe hip dislocation or femoral head deformities. This study aimed to investigate the reliability of our novel morphologic parameters and the correlations with established sagittal spinopelvic parameters. METHODS: One hundred healthy volunteers (25 male and 75 female), with an average age of 38.9 years, were analysed. Whole-body alignment in the standing position was measured using a slot-scanning X-ray imager. We measured the established spinopelvic sagittal parameters and a novel parameter: the sacral incidence to pubis (SIP). The correlation coefficient of each parameter, regression equation of PI using SIP, and regression equation of lumbar lordosis (LL) using PI or SIP were obtained. The intraclass correlation coefficient (ICC) was calculated as an evaluation of the measurement reliability. RESULTS: Reliability analysis showed high intra- and inter-rater agreements in all the spinopelvic parameters, with ICCs > 0.9. The SIP and pelvic inclination angle (PIA) demonstrated strong correlation with PI (R = 0.96) and pelvic tilt (PT) (R = 0.92). PI could be predicted according to the regression equation: PI = - 9.92 + 0.905 * SIP (R = 0.9596, p < 0.0001). The ideal LL could be predicted using the following equation using PI and age: ideal LL = 32.33 + 0.623 * PI - 0.280 * age (R = 0.6033, p < 0.001) and using SIP and age: ideal LL = 24.29 + 0.609 * SIP - 0.309 * age (R = 0.6177, p < 0.001). CONCLUSIONS: Both SIP and PIA were reliable parameters for determining the morphology and orientation of the pelvis, respectively. Ideal LL was accurately predicted using the SIP with equal accuracy as the PI. Our findings will assist clinicians in the assessment of spinopelvic sagittal alignment. TRIAL REGISTRATION: This study was retrospectively registered with the UMIN Clinical Trials Registry ( UMIN000042979 ; January 13, 2021).

Compensation for standing posture by whole-body sagittal alignment in relation to health-related quality of life.

AIMS: The aim of this study is to test the hypothesis that three grades of sagittal compensation for standing posture (normal, compensated, and decompensated) correlate with health-related quality of life measurements (HRQOL). METHODS: A total of 50 healthy volunteers (normal), 100 patients with single-level lumbar degenerative spondylolisthesis (LDS), and 70 patients with adult to elderly spinal deformity (deformity) were enrolled. Following collection of demographic data and HRQOL measured by the Scoliosis Research Society-22r (SRS-22r), radiological measurement by the biplanar slot-scanning full body stereoradiography (EOS) system was performed simultaneously with force-plate measurements to obtain whole body sagittal alignment parameters. These parameters included the offset between the centre of the acoustic meatus and the gravity line (CAM-GL), saggital vertical axis (SVA), T1 pelvic angle (TPA), McGregor slope, C2-7 lordosis, thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), PI-LL, sacral slope (SS), pelvic tilt (PT), and knee flexion. Whole spine MRI examination was also performed. Cluster analysis of the SRS-22r scores in the pooled data was performed to classify the subjects into three groups according to the HRQOL, and alignment parameters were then compared among the three cluster groups. RESULTS: On the basis of cluster analysis of the SRS-22r subscores, the pooled subjects were divided into three HRQOL groups as follows: almost normal (mean 4.24 (SD 0.32)), mildly disabled (mean 3.32 (SD 0.24)), and severely disabled (mean 2.31 (SD 0.35)). Except for CAM-GL, all the alignment parameters differed significantly among the cluster groups. The threshold values of key alignment parameters for severe disability were TPA > 30°, C2-7 lordosis > 13°, PI-LL > 30°, PT > 28°, and knee flexion > 8°. Lumbar spinal stenosis was found to be associated with the symptom severity. CONCLUSION: This study provides evidence that the three grades of sagittal compensation in whole body alignment correlate with HRQOL scores. The compensation grades depend on the clinical diagnosis, whole body sagittal alignment, and lumbar spinal stenosis. The threshold values of key alignment parameters may be an indication for treatment. Cite this article: Bone Joint J 2020;102-B(10):1359-1367.

Correction surgery for adult spinal deformity improves not only spinopelvic alignment but also the three-dimensional alignment of the lower extremities.

BACKGROUND: It is well known that correction surgery for adult spinal deformity (ASD) improves sagittal and coronal spinopelvic alignment, but the surgery effect on lower extremities (LE) is not well clarified. The aim of this study was to test the hypothesis that LE alignment also improves following spinopelvic correction surgery for ASD as a function of compensatory mechanism, and to clarify an effect of the severity of knee osteoarthritis (OA) on the improvement. METHODS: We retrospectively evaluated spinopelvic alignment, hip knee ankle angle (HKA), knee flexion angle (KF), and severity of the knee OA in thirty-nine patients with ASD before, two weeks and three months after the surgery. The grade of knee OA was evaluated by Kellgren Lawrence grading, and classified grade 0 to 2 into mild, and 3, 4 into severe OA. All the values were compared by paired t test or Wilcoxon signed rank test with significant p value of <0.05. RESULTS: Following the surgery, not only spinopelvic, but also bilateral HKA and KF were significantly improved. HKA in mild OA side was more normalized compared to that in severe side. Although KF of both bilateral mild and bilateral severe OA groups improved, the improvement of mild group was more significant. CONCLUSION: The 3D alignment of LE improved following spinopelvic correction surgery. The improvement was inadequate in cases with severe knee OA.

Relative position of sacral base in the pelvis and its correlation with spino-pelvic parameters.

PURPOSE: To investigate the relationship between relative location of the sacral base and spinal alignment in standing healthy adult volunteers. METHODS: One hundred seventy-two volunteers (men = 83, mean age = 39.3 years [20-70], women = 89, mean age = 39.6 years [20-62]) with no history of spinal disease were imaged using a low-dose biplanar slot-scanning 3D X-ray imaging system. A circle was drawn around three points: cranial vertex of the iliac crest (A), caudal vertex of the ischium (B), and anterior vertex of the pubis. Pelvic height (PH) was defined as the diameter (A-B). A tangent line perpendicular to PH (C) was drawn by passing through (A). Sacral height (SH) was defined as the distance between (C) and the center of the sacral base parallel to PH. Relative SH (rSH) was calculated as SH/PH × 100. RESULTS: Mean (SD) rSH was 18.3 ± 3.2 (men 20.0 ± 2.9, women 16.7 ± 2.6). rSH significantly positively correlated with thoracic kyphosis (r = 0.20, p < 0.05), lumbar lordosis (r = 0.28, p < 0.05), pelvic incidence (r = 0.28, p < 0.05), and sacral slope (r = 0.32, p < 0.0001), and significantly negatively correlated with pelvic thickness (r = - 0.66, p < 0.0001). rSH did not correlate with pelvic tilt. CONCLUSION: The center of the sacral base is normally located 3.8 ± 0.8 cm caudal to the cranial vertex of the iliac crest. The sacral base was located more caudally in men than in women, regardless of age. The more caudal the sacral base, the angle of the spino-pelvic parameters (TK, LL, PI, SS) progressively increases along with a decrease in the sacro-acetabular distance (Pth). Pelvic tilt did not correlate with the location of the sacrum.

Etiology and clinical manifestations of double-level versus single-level lumbar degenerative spondylolisthesis.

BACKGROUND: The differences in etiology, clinical manifestation, and whole body standing alignment between single-level LDS (sLDS) and double-level LDS (dLDS) have not been sufficiently clarified. We hypothesized that the etiology and manifestations of dLDS differ from those of sLDS. This study aimed to test this hypothesis. METHODS: A total of 112 cases with sLDS, 25 cases with dLDS, and 50 healthy volunteers as a normal control were enrolled in the study. Following the data collection on demographic and Health-related quality of life (HRQOL) by ODI and SRS-22, radiologic measurement by EOS system and MRI examination including lumbar spinal stenosis (LSS), facet angle, and segmental instability defined by facet opening were performed. All the parameters were compared among the groups. Correlations among radiologic parameters and HRQOL were analyzed. Risk factors for sLDS and dLDS were investigated respectively using multivariate logistic analysis. RESULTS: Age is the most important etiologic factor of sLDS; whereas high PI, age, and sagittally oriented facet joints are the important factors for dLDS. HRQOL significantly correlates with sagittal alignment. HRQOL does not, however, significantly differ between patients with sLDS and dLDS. Although the mean value of %slip was higher in the dLDS group than in the sLDS group, the difference was not statistically significant. %slip positively correlated with the PI. The number of spinal stenoses (LSS) per patient is significantly higher in patients with dLDS than in patients with sLDS. The HRQOL does not, however, correlate with the number of LSS. CONCLUSIONS: Age is the most important etiologic factor of sLDS; whereas high PI, age, and sagittally oriented facet joints are the important factors for dLDS. HRQOL does not significantly differ between patients with sLDS and dLDS. Number of LSS is significantly higher in dLDS than in sLDS without statistical difference in terms of HRQOL outcome.

Lumbar lordosis does not correlate with pelvic incidence in the cases with the lordosis apex located at L3 or above.

PURPOSE: To test the hypothesis that the relationship between PI and L1-S1 lumbar lordosis (LL) is always positive, even in cases with different lumbar sagittal profiles. METHODS: Standing whole-spine sagittal alignment was measured with EOS system in 100 healthy adults (46 men, 54 women, mean age 40.9 years). The apex of lumbar lordosis was defined as the most anterior lumbar vertebra or intervertebral disk from the gravity line determined by a force plate measurement. Subjects were stratified into three groups: the upper group with an apex between L1 and L3 (UppA, n = 19), the middle group with an apex from L3/4 to L4/5 (MidA, n = 67), and the lower group with an apex at L5 or below (LowA, n = 14). PI, PT, SS, thoracic kyphosis (TK), LL, SVA, T1 pelvic angle, and knee flexion angle were compared between the groups. The correlation between LL and PI in each group was also compared. RESULTS: PI and SS differed significantly between the three groups, and LL was significantly different between LowA and MidA and UppA. TK and KF did not differ significantly between groups. LL and PI were significantly positively correlated in the MidA and LowA groups, but not in the UppA group. CONCLUSION: Contrary to the hypothesis, the correlation coefficient between PI and LL was not significant in the cases with apex above L3, suggesting that the relationship between PI and LL is not always constant, and whole sagittal alignment should be taken into account. These slides can be retrieved under Electronic Supplementary Material.

Difference in whole spinal alignment between supine and standing positions in patients with adult spinal deformity using a new comparison method with slot-scanning three-dimensional X-ray imager and computed tomography through digital reconstructed radiography.

BACKGROUND: A precise comparison of supine and standing whole spine alignment in both the coronal and sagittal planes, including the pelvic parameters, has not been reported. Furthermore, previous studies investigated positional differences in the Cobb angle only in young patients with idiopathic scoliosis. The difference in alignment has never been investigated in a population of patients with adult spinal deformity (ASD). In most cases, ASD patients are aware of the symptoms when standing and tend to stoop with back pain, whereas the symptoms disappear when lying on a bed. Therefore, it is important to elucidate the positional differences in the deformity in older adults. The purposes of this study are to establish a method for comparing whole spine alignment between supine and standing, and to clarify the positional difference of the alignment in the patients with ASD. METHODS: Twenty-four patients with ASD (mean age: 60.1 years, range 20-80 years; 24 women) were evaluated. A slot-scanning three-dimensional X-ray imager (EOS) was used to assess the whole spine in the standing position. Computed tomography was used to assess the whole spine in the supine position. The computed tomography DICOM dataset of the whole spine in the supine position was transformed to two-dimensional (coronal and sagittal) digital reconstructed radiography images. The digital reconstructed radiography images were input for three-dimensional measurement by the EOS software and compared with the standing whole spine alignment measured by EOS. RESULTS: The mean intraclass correlation coefficients (supine, standing) of intra-rater / inter-rater reliabilities for the measured parameters were 0.981, 0.984 / 0.970, 0.986, respectively. The Cobb and rotation angles of the major curve, mostly the thoracolumbar area, were significantly greater in the standing position than in the supine position. Lumbar lordosis during standing was significantly kyphotic. With respect to the pelvic parameters, the sacral slope was significantly smaller in the standing position than in the supine position. Pelvic tilt and pelvic incidence were significantly greater in the standing position than in the supine position. CONCLUSIONS: The lumbar to pelvic parameters and the major curve in standing position significantly deteriorate compared with the supine position in patients with ASD.

Relationship between sagittal radiographic parameters and disability in patients with spinal disease using 3D standing analysis.

PURPOSE: To clarify the relationship between whole body sagittal radiographic parameters and health related quality of life (HRQOL) in patients with spinal disease, and further analyse such relationship based on the pelvic incidence (PI) value. METHODS: 100 patients (mean age: 64.4 years, M/F=50/50) with lumbar degenerative disease or spinal deformity were prospectively investigated. Following oswestry disability index (ODI) and scoliosis research society score 22 (SRS-22) questionnaire, whole body sagittal x-ray parameters were measured using a slot-scanning 3D x-ray imager (EOS). Correlations between such radiographic parameters and ODI/SRS-22 scores were analysed. Then, patients were divided into three groups based on the PI value (PI≤45°, 4560°) group showed a strong correlation (R>0.4) with both ODI and SRS-22 scores for PI-LL parameter. CONCLUSIONS: PI and FBI showed a significant correlation with both ODI and SRS-22 scores. PI-LL mismatch was strongly correlated with disability in high PI patients. Our study results may indicate that it is important to pay attention to the PI value in addition to the spinopelvic relationship. LEVEL OF EVIDENCE: II, prospective study.

Sagittal balance measures are more reproducible when measured in 3D vs in 2D using full-body EOS® images.

PURPOSE: An innovative low-dose X-ray biplanar imager (EOS®) allows measurement of the whole-body in standing-position which is necessary for the evaluation of spinal deformities. METHODS: A total of 60 asymptomatic subjects (ages 20-81 years) were evaluated using the 3D workflow called postural assessment and 2D measures. Subjects were measured twice each by two new observers following training, including: lordosis/kyphosis, pelvic parameters, sagittal-vertical axis, and spinal-sacral angle. Intra- and inter-observer reproducibility and similarity were compared between 2D and 3D measures. RESULTS: The intraclass correlation coefficient (ICC) was very high for the 3D measures (>0.9) and excellent for the 2D measures (>0.75). In all cases, the overall mean absolute difference between repeated 3D measures was less than 2°, or 2 mm. For all parameters, the inter- and intra-observer reproducibility in 3D measures were significantly superior to 2D measures (p < 0.03). CONCLUSION: This study demonstrated that 3D measures have better reproducibility than 2D for sagittal balance. KEY POINTS: • Reproducibility of sagittal balance 2D/3D measurements was evaluated using EOS® full-body radiographs. • Inter- and intra-observer reproducibility were significantly superior for 3D measures vs. 2D. • 3D measures have better reproducibility than 2D for sagittal balance.

Standing sagittal alignment of the whole axial skeleton with reference to the gravity line in humans.

Human beings stand upright with the chain of balance beginning at the feet, progressing to the lower limbs (ankles, knees, hip joints, pelvis), each of the spinal segments, and then ending at the cranium to achieve horizontal gaze and balance using minimum muscle activity. The details of the alignment and balance of the chain, however, are not clearly understood, due to the lack of information regarding the three-dimensional (3D) orientation of all bony elements in relation to the gravity line (GL). We performed a clinical study to clarify the standing sagittal alignment of whole axial skeletons in reference to the GL using the EOS slot-scanning 3D X-ray imaging system with simultaneous force plate measurement in a healthy human population. The GL was defined as a vertical line drawn through the centre of vertical pressure measured by the force plate. The present study yielded a complete set of physiological alignment measurements of the standing axial skeleton from the database of 136 healthy subjects (a mean age of 39.7 years, 20-69 years; men: 40, women: 96). The mean offset of centre of the acoustic meati from the GL was 0.0 cm. The offset of the cervical and thoracic vertebrae was posterior to the GL with the apex of thoracic kyphosis at T7, 5.0 cm posterior to the GL. The sagittal alignment changed to lordosis at the level of L2. The apex of the lumbar lordosis was L4, 0.6 cm anterior to the GL, and the centre of the base of the sacrum (CBS) was just posterior to the GL. The hip axis (HA) was 1.4 cm anterior to the GL. The knee joint was 2.4 cm posterior and the ankle joint was 4.8 cm posterior to the GL. L4-, L5- and the CBS-offset in subjects in the age decades of 40s, 50s and 60s were significantly posterior to those of subjects in their 20s. The L5- and CBS-offset in subjects in their 50s and 60s were also significantly posterior to those in subjects in their 30s. HA was never posterior to the GL. In the global alignment, there was a positive correlation between offset of C7 vertebra from the sagittal vertical axis (a vertical line drawn through the posterior superior corner of the sacrum in the sagittal plane) and age, but no correlation was detected between the centre of the acoustic meati-GL offset and age. Cervical lordosis (CL), pelvic tilt (PT), pelvic incidence, hip extension, knee flexion and ankle dorsiflexion increased significantly with age. Our results revealed that aging induces trunk stooping, but the global alignment is compensated for by an increase in the CL, PT and knee flexion, with the main function of CL and PT to maintain a horizontal gaze in a healthy population.

Normative values of spino-pelvic sagittal alignment, balance, age, and health-related quality of life in a cohort of healthy adult subjects.

PURPOSE: To elucidate the normative values of whole body sagittal alignment and balance of a healthy population in the standing position; and to clarify the relationship among the alignment, balance, health-related quality of life (HRQOL), and age. METHODS: Healthy Japanese adult volunteers [n = 126, mean age 39.4 years (20-69), M/F = 30/96] with no history of spinal disease were enrolled in a cross-sectional cohort study. The Oswestry Disability Index (ODI) questionnaire was administered and subjects were scanned from the center of the acoustic meati (CAM) to the feet while standing on a force plate to determine the gravity line (GL), and the distance between CAM and GL (CAM-GL) was measured in the sagittal plane. Standard X-ray parameters were measured from the head to the lower extremities. ODI was compared among age groups stratified by decade. Correlations were investigated by simple linear regression analysis. Ideal lumbar lordosis was investigated using the least squares method. RESULTS: The present study yielded normative values for whole standing sagittal alignment including head and lower extremities in a cohort of 126 healthy adult volunteers, comparable to previous reports and thus a formula for ideal lumbar lordosis was deduced: LL = 32.9 + 0.60 × PI - 0.23 × age. There was a tendency of positive correlation between McGregor slope, thoracic kyphosis, PT, and age. SVA, T1 pelvic angle, sacrofemoral angle, knee flexion angle, and ankle flexion angle, but not CAM-GL, increased with age, suggesting that the spinopelvic alignment changes with age, but standing whole body alignment is compensated for to preserve a horizontal gaze. ODI tended to increase from the 40s in the domain of pain intensity, personal care, traveling, and total score. ODI weakly, but significantly positively correlated with age and PI-LL. CONCLUSION: Whole body standing alignment even in healthy subjects gradually deteriorates with age, but is compensated to preserve a horizontal gaze. HRQOL is also affected by aging and spinopelvic malalignment.