Impact of Sagittal Plane Spinal Deformity on the Spino-Pelvic Relationship and Gravity Line Position in Adults

Introduction: Sagittal spinal imbalance in the adult remains poorly understood and challenging. Limitations of radiographic analysis have lead researchers to apply forceplate technology to enhance the study of spinal balance through evaluation of the gravity line (GL). The aim of this study was to investigate differences between asymptomatic adults and patients with sagittal spinal deformities, with a hypothesis that imbalance would lead to changes in the GL - spinal relationship.

Material and Method: This prospective study included 44 asymptomatic subjects (mean 57yo) and 40 patients with sagittal deformities (mean 65yo, inclusion criteria: L1-S1 lordosis<25 , Pelvic Tilt>20, C7 plumbline>5 cm). Coronal plane deformities were excluded. Full-length free-standing sagittal radiographs were obtained with simultaneous acquisition of the GL and heel position (by forceplate). Spino-pelvic radiographic parameters were calculated and distances (offsets) from the GL analyzed. Group differences were evaluated by independent sample t-tests.

Results: Groups did not differ in age, thoracic kyphosis, offsets from femoral heads to heels, femoral heads to GL, and GL to heels. As per inclusion criteria the sagittal deformity group had greater mean C7 plumbline (8cm vs 0cm), increased pelvic tilt (27 vs 13 ) and loss of lordosis (46 vs 58 ). The sagittal deformity group also had greater pelvic incidence (60 vs 51 ), anterior trunk inclination (-3 vs -11 ), S1 displacement toward the heels (distance decreased, 87 vs. 46mm). All differences p<0 .001.

Discussion: The sagittal spinal deformity group revealed marked differences; the sacrum has a more posterior position in relation to the GL and heels. However, the GL to femoral head offset was not markedly influenced. The additional finding of no change in the GL to heel offset and rather fixed GL-femoral head offset appears to indicate that sagittal spinal deformity induces a posterior sacral translation and pelvic retroversion in order to maintain a fixed GL-heel relationship.