Introduction The main objective of all the sagittal compensating mechanisms is to allow a subject to stand and keep an erect position. Materials and methods The cascade of compensating mechanisms appears progressively with the increasing amount of imbalance of the spine until compensation is no longer possible. The loss of lumbar lordosis can be considered as the initiating event of sagittal imbalance. This loss of the normal lordosis pushes the C7 plumb line forward. Results The assessment of sagittal balance has to include to be complete: a parameter measuring the global balance of the trunk, either C7 plumb line and sacral plateau, the position of the pelvis rotation by the pelvic tilt, and a description of the position of the lower limbs. Those three parameters have been taken into account by the newly described method called full balance integrated (FBI). This evaluation is easily done on a sagittal full spine standing X-ray from C2 to the pelvis, including the first 10 cm of the femur. Conclusion Three questions to answer: What is the value of the pelvis incidence? Is the patient balanced? Are there compensatory mechanisms?
A retrospective analysis of adults treated with long instrumented fusion for scoliosis from the thoracic spine proximally to L4 or L5. To evaluate the long-term clinical outcomes as well as radiological changes in distal unfused mobile segments and to evaluate factors that may predispose to distal disc degeneration and/or poor outcome. A total of 151 mobile segments in 85 patients (65 female), mean age 43.2 (range 21-68), were studied. Curve type, number of fused levels and pelvic incidence were recorded. Clinical outcome was measured using the Whitecloud function scale and disc degeneration using the UCLA disc degeneration score. Spinal balance, local segmental angulations and lumbar lordosis were measured pre-and postoperatively as well as at the most recent follow up-mean 9.3 years (range 7-19). A total of 62% of patients had a good or excellent outcome. Eleven had a poor outcome of which ten underwent extension of fusion-five for pain alone, three for pain with stenosis and two for pseudarthroses. Pre-operative disc degeneration was often asymmetric and was slightly greater in older patients. Overall, there was a significant deterioration in disc degeneration (P \ 0.0001) that did not correlate with clinical outcome. Disc degeneration correlated with the recent sagittal balance (Anova F = 14.285, P \ 0.001) and the most recent lordosis (Anova F = 4.057, P = 0.048). The post-operative sagittal balance and local L5-S1 sagittal angulation correlated to L4 and L5 degeneration, respectively. There was no correlation between degeneration and age, pre-operative degenerative score, pelvic incidence, sacral slope, number of fused levels or distal level of fusion. Disc degeneration does occur below an arthrodesis for scoliosis in adults which does not correlate with clinical outcome. The correlation of loss of sagittal balance with disc degeneration may be as a result of degeneration causing the loss of balance or vice versa, i.e. sagittal imbalance causing degeneration. Immediate postoperative imbalance correlates with degeneration of the L4/5 disc, which may imply the latter.
The main objective of this study is to determine the prevalence of coronal abnormalities of the lumbar spine in a large population of patients with respect to their age and sex. Lumbar degenerative disease is associated with degenerative scoliosis. Degenerative scoliosis and lateral listhesis are important features to identify before decompressive surgery as deformity may not be seen on magnetic resonance imaging scans. Scoliosis and lateral listhesis may be important in the development of symptoms especially in an ageing population. All abdominal and plain kidney-ureter-bladder radiographs performed over a 10-month period were reviewed. 2,765 radiographs were assessed for scoliosis (Cobb angle greater then 10°), lateral listhesis and evidence of osteoarthritis. The prevalence of scoliosis, lateral listhesis and osteoarthritis of the lumbar spine increased with age. Scoliosis and lateral listhesis were significantly more prevalent in women. Deformity starts to occur after the age of 50 and steadily increases with age. By the ninth decade nearly a quarter of patients have evidence of scoliosis and lateral listhesis. As the adult lumbar spine ages, the prevalence of lateral listhesis and degenerative scoliosis increases. It is important to appreciate these coronal abnormalities in patients undergoing decompressive surgery for spinal stenosis. This increase in deformity may have a greater impact as the population continues to age.
Between 1979 and 1996, 40 patients with high-grade lumbosacral spondylolisthesis were treated in our institution using a newly designed osteosynthesis device. The mean age was 13 years and 6 months, and the mean follow-up was 18 years. Combined posterior decompression and anterior reduction, instrumentation and fusion of the slippage were performed in all cases. The technique includes reduction of the slippage by means of an anteriorly placed plate that engages two screws, previously placed during the posterior approach, going through the S1 vertebra. Progressive compression applied on the plate by the screws achieves reduction. Complete fusion was obtained in all 40 patients. Twelve patients presented a postoperative radiculopathy, from which only ten recovered completely. There were six L4-L5 annulus lesions, responsible for instability, produced by the plate. We report five late infections. Thirty-five of the forty patients were asymptomatic at the latest follow-up. The double compressive plate technique proved to be effective in obtaining lumbosacral fusion and optimal slippage reduction. However, the high rates of neurological and infectious complications preclude recommendation of this technique in its present form.
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