Hip–spine relations and sagittal balance clinical consequences

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Abstract

Introduction

The role of the pelvic area in sagittal balance is evident for spinal surgeons, but the influence of the coxofemoral joint is underestimated and inadequately explained by conventional imagery. Comprehensive analysis of the pelvic and subpelvic sectors as part of the sagittal, frontal and cross-sectional balance of the trunk sheds new light on some spinal diseases and their relation to the pelvis.

Methods

This analysis, based on innovative radiologic methods as the EOS ^® technology but also on a new look at conventional imaging makes it possible to better analyze standing lateral images and seated images.

Results

Disturbances can come from atypical morphotypes or from unusual postures as in aging spine. The measurement of available extension and the concept of available flexion provide new information regarding individual’s adaptation to the imbalance induced by disorders of the spine or lower limbs.

Conclusion

A comprehensive assessment of each patient and in particular of the complex comprising the spine and the pelvis, is essential for understanding each individual’s adaptation to the imbalance induced by disorders of the spine or lower limbs.

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Most cited references 32

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Radiographic analysis of the sagittal alignment and balance of the spine in asymptomatic subjects.

Raphaël Vialle, Nicolas Levassor, Ludovic Rillardon … (2005)

There is an increasing recognition of the clinical importance of the sagittal plane alignment of the spine. A prospective study of several radiographic parameters of the sagittal profile of the spine was conducted to determine the physiological values of these parameters, to calculate the variations of these parameters according to epidemiological and morphological data, and to study the relationships among all of these parameters. Sagittal radiographs of the head, spine, and pelvis of 300 asymptomatic volunteers, made with the subject standing, were evaluated. The following parameters were measured: lumbar lordosis, thoracic kyphosis, T9 sagittal offset, sacral slope, pelvic incidence, pelvic tilt, intervertebral angulation, and vertebral wedging angle from T9 to S1. The radiographs were digitized, and all measurements were performed with use of a software program. Two different analyses, a descriptive analysis characterizing these parameters and a multivariate analysis, were performed in order to study the relationships among all of them. The mean values (and standard deviations) were 60 degrees 10 degrees for maximum lumbar lordosis, 41 degrees +/- 8.4 degrees for sacral slope, 13 degrees +/- 6 degrees for pelvic tilt, 55 degrees +/-10.6 degrees for pelvic incidence, and 10.3 degrees +/- 3.1 degrees for T9 sagittal offset. A strong correlation was found between the sacral slope and the pelvic incidence (r = 0.8); between maximum lumbar lordosis and sacral slope (r = 0.86); between pelvic incidence and pelvic tilt (r = 0.66); between maximum lumbar lordosis and pelvic incidence, pelvic tilt, and maximum thoracic kyphosis (r = 0.9); and, finally, between pelvic incidence and T9 sagittal offset, sacral slope, pelvic tilt, maximum lumbar lordosis, and thoracic kyphosis (r = 0.98). The T9 sagittal offset, reflecting the sagittal balance of the spine, was dependent on three separate factors: a linear combination of the pelvic incidence, maximum lumbar lordosis, and sacral slope; the pelvic tilt; and the thoracic kyphosis. This description of the physiological spinal sagittal balance should serve as a baseline in the evaluation of pathological conditions associated with abnormal angular parameter values. Before a patient with spinal sagittal imbalance is treated, the reciprocal balance between various spinal angular parameters needs to be taken into account. The correlations between angular parameters may also be useful in calculating the corrections to be obtained during treatment.

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The definition and measurement of acetabular orientation.

Brendan D. Murray (1993)

The orientation of an acetabulum or an acetabular prosthesis may be described by its inclination and anteversion. Orientation can be assessed anatomically, radiographically, and by direct observation at operation. The angles of inclination and anteversion determined by these three methods differ because they have different spatial arrangements. There are therefore three distinct definitions of inclination and anteversion. This paper analyses the differences between the definitions and provides nomograms to convert from one to another. It is recommended that the operative definitions be used to describe the orientation of prostheses and that the anatomical definitions be used for dysplastic acetabula.

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Sagittal alignment in lumbosacral fusion: relations between radiological parameters and pain.

J Y Lazennec, S Ramaré, N Arafati … (2000)

The objective of this study was to conduct a radiological analysis of posture before and after lumbosacral fusion to evaluate the influence of spinal alignment on the occurrence and pattern of post surgical pain. The study included 81 patients, of whom 51 had a history of previous low back surgery. We excluded patients with suspected or confirmed nonunion. In the fusion group, the 27 patients who were pain free after the procedure were compared to the 54 patients with residual pain. Thirty patients had pain only or primarily when they were standing immobile, 18 when they were sitting immobile, and six in both positions. Measurements were done on full-length lateral radiographs of the spine, with the patient standing according to Duval Beaupère criteria. The subgroup with postfusion pain was characterized at baseline by a more vertical sacrum with less sacral tilt (ST) (P < 0.0062) and more pelvic tilt (PT) (P < 0.0160). PT at last follow-up (PT fu) correlated with the presence of postfusion pain (NP: P = 0.0003). In the patients with postfusion pain, PT was almost twice the normal value. ST at last follow-up (ST fu) in the standing position was also correlated with the presence of postfusion pain (P < 0.0001) indicating that the sacrum remained abnormally vertical in the subjects with postfusion pain. Using logistic regression, the only prognostic factor for residual pain at last follow-up was ST fu. Both at pre-operative evaluation and at last follow-up, patients with pain in the standing position or in both the standing and sitting positions were characterized at pre-operative status by a more vertical sacrum with less sacral tilt. The results of this study indicate that, achieving a strong fusion should not be the only goal. Appropriate position of the fused vertebrae is also of paramount importance to minimize muscle work during posture maintenance. The main risk is failing to correct or to causing excessive pelvic retroversion with a vertical sacrum leading to a sagittal alignment that replicates the sitting position. This situation is often accompanied by loss of lumbar lordosis and adversely affects stiff or degenerative hips.

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Author and article information

Contributors

: lazennec.jy@wanadoo.fr

Journal

Journal ID (nlm-ta): Eur Spine J

Title: European Spine Journal

Publisher: Springer-Verlag (Berlin/Heidelberg )

ISSN (Print): 0940-6719

ISSN (Electronic): 1432-0932

Publication date (Electronic): 28 July 2011

Publication date PMC-release: 28 July 2011

Publication date (Print): September 2011

Volume: 20

Issue: Suppl 5

Pages: 686-698

Affiliations

[1 ]Service de chirurgie orthopédique, Hôpital Pitié Salpêtrière, Université Pierre et Marie Curie, Assistance Publique-Hôpitaux de Paris, Paris 6, 83 bd de l’hôpital, 75013 Paris, France

[2 ]Ingénieur de recherches cliniques, Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France

Article

Publisher ID: 1937

DOI: 10.1007/s00586-011-1937-9

PMC ID: 3175930

PubMed ID: 21796392

SO-VID: 24ce8859-6fd6-462f-8453-f0e85d8ae7c3

History

Date received : 11 July 2011

Date accepted : 11 July 2011

Custom metadata

ScienceOpen disciplines: Orthopedics

Keywords: eos imaging,incidence angle,acetabular anteversion,anterior pelvic plane,hip prosthesis impingement,sagittal balance,hip range of motion,hip prosthesis dislocation,pelvic tilt

Data availability:

ScienceOpen disciplines: Orthopedics

Keywords: eos imaging, incidence angle, acetabular anteversion, anterior pelvic plane, hip prosthesis impingement, sagittal balance, hip range of motion, hip prosthesis dislocation, pelvic tilt

Hip–spine relations and sagittal balance clinical consequences

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Abstract

Introduction

Methods

Results

Conclusion

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Orthopedics

Most cited references 32

Radiographic analysis of the sagittal alignment and balance of the spine in asymptomatic subjects.

The definition and measurement of acetabular orientation.

Sagittal alignment in lumbosacral fusion: relations between radiological parameters and pain.

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