Sie sind auf Seite 1von 11

Edited by Foxit Reader

Copyright(C) by Foxit Software Company,2005-2007

For Evaluation Only.

Neurosurg Clin N Am 17 (2006) 353363

Sagittal Imbalance
Peter D. Angevine, MD, MPHa,*, Keith H. Bridwell, MDb

Department of Neurological Surgery, Columbia University College of Physicians and Surgeons,

710 West 168th Street, Room 510, New York, NY 10032, USA
Department of Orthopaedic Surgery, Washington University in St. Louis, One Barnes-Jewish Hospital Plaza,
Suite 11300 West Pavilion, Campus Box 8233, St. Louis, MO 63110, USA

Sagittal imbalance is a general term encompassing spinal deformities that include a signicant
component of forward postural instability. Conceptually, sagittal imbalance results from a loss
of harmony between the normal regional contours
of the spine. Bernhardt and Bridwell [1] determined that a well-balanced spine generally has between 10 and 30 more lumbar lordosis than
thoracic kyphosis. A relative loss of lumbar lordosis, increase in thoracic kyphosis, or combination
of the two may result in an anterior progression of
the proximal spine relative to the distal spine and
pelvis resulting in sagittal imbalance. Underlying
causes may include ankylosing spondylitis, spinal
arthrodesis in suboptimal alignment, pseudarthrosis, post-traumatic kyphosis, or degenerative disk
disease [25].
Sagittal imbalance may be segmental (type 1)
or global (type 2). Segmental sagittal imbalance
refers to a regional relative kyphosis (loss of
normal lordosis, frank kyphosis of normally
lordotic segment, or hyperkyphosis) with preserved C2 or C7 plumb line alignment (centered
over L5-S1 disk). To maintain overall normal
sagittal balance in the setting of regional relative
kyphosis, a distal hyperlordosis is generally present. Global sagittal imbalance is a deformity that
results in positive overall sagittal balance (C2 or
C7 plumb line O5 cm ventral to L5-S1 disk) [3].
Patients with sagittal imbalance may present
with complaints referable to the segmental or

* Corresponding author.
E-mail address:
(P.D. Angevine).

local disorder or to the global imbalance or

both. Compensatory distal hyperlordosis also
may accelerate disk degeneration and be associated with pain. Typical symptoms include low
back pain, diculty with ambulation, and inability to maintain forward gaze when upright.
Glassman and colleagues [6] found that symptom
severity as measured by SF-12, SRS, and Oswestry questionnaires correlated weakly with the degree of positive sagittal balance.
The operative treatment of sagittal imbalance
is complex and potentially associated with significant complications. The spinal surgeon must plan
nonoperative or operative treatment to address all
facets of the deformity adequately, while minimizing the opportunity for untoward events or
a suboptimal outcome. Avoidance of complications involves thorough preoperative planning,
meticulous technical execution, and attentive
postoperative management.
The preoperative planning begins with taking
a careful history and performing a directed physical
examination. Radiographic studies are obtained
and analyzed, and the surgeon formulates a surgical
plan to address the patients complaints and
the spinal pathology. The nal key component
of the preoperative planning is a frank discussion
with the patient regarding the proposed operation.
Surgery for the correction of sagittal imbalance is
a large undertaking; it is crucial that the patient has
a clear understanding of the procedure and its
potential risks and a reasonable expectation of the
potential outcomes.

1042-3680/06/$ - see front matter 2006 Elsevier Inc. All rights reserved.


Edited by Foxit Reader

Copyright(C) by Foxit Software Company,2005-2007
For Evaluation Only.

Deformity evaluation
Evaluation of the spinal deformity begins with
the clinical examination. The surgeon evaluates the
overall clinical sagittal and coronal balance and
associated factors, such as the ability of the patient
to maintain forward gaze while standing and
walking. Because a patient may compensate for
the spinal deformity with hip and knee exion, the
surgeon must account for the conguration of these
joints when evaluating overall balance (Fig. 1). The
exibility of the deformity also is evaluated. The patient is asked to lie supine and prone to determine
the amount of correction obtained with these postural changes. In some cases, the patient might
need to remain supine for a time to allow relaxation
and spontaneous correction.
The most important radiographic studies in
developing the surgical plan are the upright and
supine anteroposterior and lateral radiographs of
the entire spine. The supine and upright views are
compared carefully. Assessing regional and global
sagittal balance with appropriate Cobb angles and
plumb lines using the same landmarks on each
radiograph may reveal signicant exibility in an
otherwise formidable deformity. In some patients,

particularly patients with an angular deformity in

the thoracolumbar region, lateral radiographs in
hyperextension with a padded bolster at the apex
of the kyphosis may be necessary to evaluate
exibility. The bolster location should be marked
clearly on the radiograph.
Coned-down views of particular areas of interest can help to delineate complicated anatomy,
particularly if there is a coronal plane and
a sagittal plane deformity. In osteopenic patients,
regional radiographs may show bony anatomy
better than the studies of the entire spine.
Flexibility studies typically do not reveal the
maximum spontaneous correction possible. With
general anesthesia, adequate pharmacologic muscle relaxation, and proper positioning on an openframe spine table, additional correction generally
can be obtained in a deformity with some exibility. The goal of the careful preoperative exibility evaluation is to determine if sucient exibility
exists to allow correction of the deformity solely
with manipulation or if the deformity is xed and
requires osteotomies for correction.
With segmental bilateral pedicle screw xation, the indications for anterior release for

Fig. 1. (A) Patients may compensate for xed spinal deformities with knee and hip exion. (B) Full knee extension
reveals the extent of the positive global sagittal balance.

Edited by Foxit Reader

Copyright(C) by Foxit Software Company,2005-2007
For Evaluation Only.

correction are diminishing. In the absence of

spontaneous or iatrogenic anterior fusion, significant correction usually can be obtained with
gradual, bilateral simultaneous compression over
the length of a kyphotic deformity. Combined
anterior and posterior (circumferential) surgery
may be indicated for patients with osteoporosis,
lumbar pseudarthrosis, or large coronal and
sagittal plane deformities or to increase the likelihood of fusion, particularly across the lumbosacral junction [7].
Level selection
Selection of the proper levels for instrumentation and arthrodesis is essential to obtain satisfactory short-term and long-term results.
Immobilizing inappropriate segments or too few
segments may increase the likelihood of proximal
or distal adjacent segment kyphosis. Each deformity must be evaluated individually, but some
general principles apply. The construct should not
end at the apex of a curve (in either the sagittal or
the coronal plane), but should extend to a relatively straight part of the spine; proximally, this
generally means the construct extends to the lower
thoracic spine (T9-11) or across the normal
thoracic kyphosis to the proximal thoracic region
(T2-4). Distally, the construct should extend at
least to the most proximal level that is intersected
by the posterior sacral vertical line. A long
construct seldom should end adjacent to a significantly degenerated segment to minimize the
likelihood of early adjacent level degeneration.
The fth lumbar vertebra is often not an ideal
lower instrumented vertebra for a few reasons.
First, the pedicles are usually fairly large; screw
pullout strength may be suboptimal, an important
consideration with a lengthy construct. Second,
there is only one motion segment distal to L5;
accelerated degeneration of the L5-S1 disk may
occur. There seems to be a greater risk of this
accelerated degeneration in the presence of preoperative positive sagittal balance, younger age,
and radiographic evidence of degeneration on
preoperative studies [8].
Osteotomy planning
In cases of xed sagittal imbalance, osteotomies must be performed to restore exibility to the
spine and allow correction of the deformity. The
surgeon must select the appropriate type and
location of osteotomies to restore normal sagittal
balance. Improper decision making at this step


may result in a suboptimal outcome even from

a technically satisfactory procedure. Three main
factors are considered in planning osteotomies: (1)
the presence or absence of open disk spaces at the
levels requiring correction, (2) the contour of the
region to be corrected, and (3) the amount of
correction necessary. Osteotomies may be performed through the posterior column only
(Smith-Petersen osteotomies [SPOs]) or through
all three columns (pedicle subtraction type).
Originally described for the treatment of kyphosis associated with arthritides, SPOs involve
the resection of the posterior elements in a chevron
conguration [9]. In the presence of an open disk
space, the osteotomy may be closed with compression on proximal and distal pedicle screws. The
result is a widening of the anterior column,
a shortening of the posterior column, and an increase in segmental lordosis [10]. Approximately
1 of correction can be obtained for each 1 mm
of bone resected; 5 to 10 can be obtained on average from each osteotomy.
To achieve greater single-segment lordosis or to
achieve sagittal plane correction in the absence of
anterior column exibility, a pedicle subtraction
osteotomy (PSO) may be used. The technique has
been described in detail elsewhere [11,12]. The fundamental principle is to resect a wedge of bone, widest dorsally and narrowest ventrally, through the
pedicles and to close the osteotomy using segmental
xation. Approximately 30 of correction can be
obtained from a single-level PSO [1214].
Selection of the proper level or levels for the
osteotomies is essential for acceptable postoperative alignment. Generally, osteotomies are performed in the region of relative kyphosis. An
exception may be a situation such as ankylosing
spondylitis in which the proximal and main
thoracic hyperkyphosis is not addressed directly,
but adequate compensatory lordosis is obtained
with osteotomies in the thoracolumbar or lumbar
region to correct the global sagittal imbalance [13].
Angular kyphotic deformities, such as occur
after trauma, often are treated best with an
osteotomy through the pathologic level. These
often are associated with type I (segmental)
sagittal imbalance, and a compensatory distal
hyperlordosis that maintains adequate global
balance. With correction of the focal deformity,
the compensatory curves may correct spontaneously. Typically a PSO is used to correct angular
kyphotic deformities.
Another common scenario is loss of lordosis
throughout the entire lumbar spine and positive



Fig. 2. A 56-year-old woman with a history of spinal fracture treated with noninstrumented arthrodesis approximately
30 years before presentation. Chief complaints included back pain, leg pain, and postural changes with increasing forward and leftward tilt. Clinical examination was signicant for positive sagittal balance (A) and left-sided (negative) coronal imbalance (B). Anteroposterior (C) and lateral (D) upright radiographs show xed coronal and sagittal deformity.
The patient underwent an asymmetric L3 PSO with T8 to pelvis-instrumented fusion. Postoperative anteroposterior (E)
and lateral (F) upright radiographs and clinical photographs (G) show improved coronal and sagittal balance.

Edited by Foxit Reader

Copyright(C) by Foxit Software Company,2005-2007
For Evaluation Only.

overall sagittal balance. Restoration of adequate

lumbar lordosis and correction of the type II
sagittal deformity generally require at least one
PSO. It is generally preferable to perform PSOs at
L2 or L3, when possible; this places the level of the
osteotomy below the conus, potentially decreasing
the neurologic risk associated with performing and
closing the osteotomy. Also, several (six to eight)
points of xation are available distal to the osteotomy performed at these levels. Moving the osteotomy site distally reduces the number of sites for
segmental xation and may increase the risk of
instrumentation failure, pseudarthrosis, or both.
For a given angular correction, a more distally
located osteotomy would produce a greater change
in the overall sagittal balance. The spinal surgeon
must weigh these considerations carefully when
planning any osteotomy.
The choice of type of osteotomy also must be
made with consideration of the coronal plane.
SPOs performed at or near the apex of a coronal
deformity, particularly if signicant axial rotation
is present, may increase the magnitude of the
deformity and create or exacerbate coronal imbalance [3,15]. In cases of sagittal imbalance combined
with a signicant coronal deformity in which the
appropriate level of an osteotomy is determined
to be within the coronal curve, an asymmetric
PSO is less likely to produce coronal problems because all three columns are shortened (Fig. 3) [15].
As the foregoing brief discussion indicates, the
decision making involved in planning operative
treatment of sagittal imbalance is complicated.


Although the process must be tailored to each

patient based on individual factors, a general
algorithm based on the type of sagittal imbalance
and the location of the deformity can be a helpful
guide (Fig. 2).
Preparation for wake-up test
Kyphosis corrections and osteotomy closures
may be associated with a higher rate of neurologic
complications than other deformity procedures
[16]. The patient should be thoroughly prepared
for the possibility of an intraoperative wake-up
test to verify neurologic function after corrective
maneuvers or at any time the neurophysiologic
monitoring data indicate neurologic compromise
may have occurred. At surgical planning visits,
the wake-up test should be rehearsed as it will
be performed during surgery. The patients family
should observe the testing procedure and be instructed to rehearse the examination several times
before surgery. Attention to this detail minimizes
the time necessary to obtain a satisfactory wakeup test, if one is necessary during the operation,
and reduces the associated stress and risk for the
Properly positioning the patient on the operating table takes advantage of any inherent
exibility of the deformity. An open-frame spine

Fig. 3. Algorithm for osteotomy type based on the character of the sagittal deformity. PSO, pedicle subtraction osteotomy; VCR, vertebral column resection.


Edited by Foxit Reader

Copyright(C) by Foxit Software Company,2005-2007
For Evaluation Only.

table with multiple pads can be congured to

accommodate most deformities. In severe cases of
kyphosis, padding and pillows may need to be
added to support the patient. The hips of patients
with lumbar hypolordosis may need to be exed
initially and extended during the operation to
close an osteotomy.
An ecient, meticulous exposure of the dorsal
bony elements of all vertebrae to be included in
the construct is an essential part of all spinal
deformity surgery. The surgeon uses appropriate
retractors and electrocautery, primarily monopolar, to maintain hemostasis as the exposure is
performed. To avoid exposing levels proximal or
distal to the planned construct, one initially may
expose levels near the apex of the deformity that
are clearly going to be instrumented. As the initial
exposure is completed, anteroposterior and lateral
intraoperative radiographs are taken with metallic
markers placed in readily identiable locations.
If any doubt remains on review of the initial
radiographs, additional studies must be undertaken to ensure that the proper levels are exposed.
After the proper levels are conrmed, all soft
tissue is completely removed from the dorsal
elements. The transverse processes are exposed
and cleaned to their tips. Care is taken during the
exposure to avoid entry into the spinal canal
through the interlaminar space or an iatrogenic
or congenital bony defect. Vascular branches
lateral to the pars interarticularis and the superior
facet should be anticipated and avoided. The use
of monopolar cautery ventral to the lateral pars
also should be avoided to prevent injury to the
nerve root. Particular attention is paid to preserving the dorsal tension band (supraspinous and
interspinous ligaments) proximal and distal to the
exposed levels. To minimize the likelihood of
developing adjacent segment degeneration and
Role of pain, the capsule should be left intact on facets
that are not to be immobilized.
facetectomy Partial facetectomies are performed at all levels
that are to be included in the instrumentation and
fusion. In the thoracic spine, this procedure serves
three main purposes. First, it increases the exibility of the deformity, increasing the potential for
correction. Second, meticulous removal of the
articular surfaces increases the probability of
obtaining a solid arthrodesis. Third, the identication of the starting points for midthoracic
pedicle screws is facilitated with exposure of the

superior facet. Thoracic facetectomies are performed with a sharp 1/4- or 1/2-inch osteotome. A
sagittal cut is made at the medial aspect of the
inferior facet extending 5 mm or less proximally.
An axial cut is made with care not to use excessive
force, which risks facet fracture and a potentially
devastating neurologic injury. The underlying
superior facet protects against entry into the
spinal canal with the osteotome. Lumbar facetectomies are performed most easily and rapidly with
a Leksell rongeur oriented parallel to the articular
Obtaining xation
Correction of a signicant sagittal plane deformity requires the application and maintenance
of signicant forces to the spine; this mandates
multiple secure points of xation through which
corrective forces can be transmitted. Options for
segmental spinal instrumentation for deformity
correction include hooks (pedicle, laminar, and
transverse process) and pedicle screws [3]. Although hooks have been used in the thoracic spine
for a longer time and are more familiar to many surgeons, pedicle screws oer advantages that hooks
do not. As with any complex spinal instrumentation technique, the safe, appropriate use of hooks
or pedicle screws requires thorough training.
Closure of osteotomies requires strong xation. Although there are no iron-clad rules, fewer
than four points of xation proximal and distal to
an osteotomy may not be adequate to close and
hold an osteotomy without loosening of the
implant-bone interface [14].
In cases of rigid kyphoses, partial facetectomies
may not loosen the deformity suciently to allow
adequate correction and restore normal sagittal
balance. Osteotomies provide further exibility to
the spine and, in the case of pedicle subtraction
osteotomies, allow correction in the setting of
circumferential fusion. These procedures must be
performed with meticulous attention to detail to
minimize the risk of neurologic injury.
Smith-Petersen osteotomy
The SPO (opening wedge or chevron osteotomy) allows the surgeon to shorten the posterior
column about an axis of rotation in the middle
column. The standard SPO involves removing the
ligamentum avum and the superior and inferior

Edited by Foxit Reader

Copyright(C) by Foxit Software Company,2005-2007
For Evaluation Only.

facets bilaterally at each level. The width of the

osteotomy is typically 7 to 10 mm; the width of
a standard Leksell rongeur is a convenient guide.
The rongeur is used to remove supercial ligament
and the inferior facet. Resection of the remaining
ligament and the superior facet is completed with
Kerrison punches. Hemostasis is obtained with
thrombin-soaked Gelfoam or similar products
(Fig. 4).
Closure of the SPO depends on sucient
exibility of the anterior column; an open disk
space at the level of the osteotomy is a prerequisite
(Fig. 5). If the osteotomy is excessively wide,
bone-on-bone contact is not achieved, and there
is a greater risk of pseudarthrosis.
The surgeon must be vigilant while closing the
osteotomy to ensure that the neural elements are
not compressed by the dorsal elements. Undercutting the laminae maximizes the volume of the
spinal canal, while preserving dorsal bony surfaces for arthrodesis. As the osteotomy is gradually closed, a Woodson elevator is used to verify
that the thecal sac remains free of compression.
Pedicle subtraction osteotomy
The PSO extends through all three columns of
the spine and provides a means to correct a kyphotic deformity when there is a circumferential
fusion. The axis of rotation is at the ventral
vertebral body; in contrast to the SPO, the PSO

Fig. 4. Posterior and lateral views of spine with xed

sagittal imbalance and smooth kyphotic deformity after
placement of segmental xation and multiple SPOs.


Fig. 5. Correction of kyphotic deformity after multiple

SPOs employs dorsal compression on strong segmental
xation and cantilever forces.

results in a shorter spinal canal. Greater correction can be obtained at a single level with a PSO
than with an SPO. An asymmetric PSO may be
used to correct sagittal imbalance combined with
a coronal deformity. SPOs may result in an
increase in coronal deformity particularly if signicant rotation is present [15].
The PSO technique has been described elsewhere, and a detailed description of the procedure
is beyond the scope of this article [11,12]. A few pitfalls in these technically demanding procedures can
be avoided. The posterior elements are completely
removed, and the pedicles are isolated. All removed
bone is saved for use as bone graft. Maintaining the
pedicle walls intact, particularly on the medial and
inferior aspects, facilitates bony removal from the
vertebral body by protecting the lateral dura and
the nerve root (Fig. 6). Bleeding can be brisk from
the vertebral body. Using hemostatic agents and alternating between sides can help to minimize blood
loss. After the cancellous bone has been removed
from the vertebral body, the dorsal cortex is pushed
into the defect with a down-going curette or Woodson elevator. The lateral cortical wall is the last portion of bone to be removed (Fig. 7). The surgeon
should not disarticulate the spine completely, but
should leave a ventral hinge of cortical bone.
This hinge helps to prevent a coronal shift in the
alignment, which, once it has occurred, can be


Edited by Foxit Reader

Copyright(C) by Foxit Software Company,2005-2007
For Evaluation Only.

Fig. 6. (A and B) With careful retraction on the lateral

thecal sac and nerve root, a wedge-shaped portion of cancellous bone is removed from the vertebral body through
the pedicle. (From Bridwell KH, Lewis SJ, Rinella A, et al.
Pedicle subtraction osteotomy for the treatment of xed
sagittal imbalance: surgical technique. J Bone Joint Surg
Am 2004;86A(Suppl 1):4450; reprinted with permission
from The Journal of Bone and Joint Surgery, Inc.)

dicult to correct. Securing a temporary rod to

pedicle screws proximal and distal to the osteotomy
also prevents sudden changes in the spinal
On an open-frame spine table, closure of the
PSO usually can be achieved with moderate
ventrally directed manual pressure proximal and

Fig. 7. (A and B) After the dorsal cortex has been

removed, the lateral cortical wall of the vertebral body
is resected using a Leksell rongeur. (From Bridwell
KH, Lewis SJ, Rinella A, et al. Pedicle subtraction osteotomy for the treatment of xed sagittal imbalance:
surgical technique. J Bone Joint Surg Am 2004;
86A(Suppl 1):4450; reprinted with permission from
The Journal of Bone and Joint Surgery, Inc.)

distal to the osteotomy. Additional lordosis can

be introduced with in situ rod contouring. During
the closure of the osteotomy, the hips should be
extended to maximize the lumbar lordosis.
The surgeon must ensure that the neural
elements in the spinal canal and in the enlarged
foramina produced by removing the pedicles are
free from compression. An enlarged central opening can be made to allow palpation of the spinal
canal after closure of the osteotomy (Fig. 8). Alternatively, greater proximal-distal bony removal
can be performed laterally, allowing direct inspection of the exiting nerve roots and palpation of the
central spinal canal from a lateral-to-medial direction. In either case, some dorsal bone-on-bone
contact is desirable to maximize the likelihood
of obtaining a solid posterior arthrodesis.
Long-term satisfactory results for the correction of sagittal imbalance ultimately depend on
the proper correction of the deformity and a solid
arthrodesis across all instrumented levels. Preparation of the fusion bed begins with the meticulous cleaning of all dorsal bony surfaces during
the initial exposure. After correction has been

Fig. 8. (A and B) The osteotomy is closed using dorsal

compression, and the spinal canal and neural foramina
are carefully probed to ensure that no compression of
the neural elements has occurred. (From Bridwell KH,
Lewis SJ, Rinella A, et al. Pedicle subtraction osteotomy
for the treatment of xed sagittal imbalance: surgical
technique. J Bone Joint Surg Am 2004;86A(Suppl 1):
4450; reprinted with permission from The Journal of
Bone and Joint Surgery, Inc.)

Edited by Foxit Reader

Copyright(C) by Foxit Software Company,2005-2007
For Evaluation Only.

obtained, and the implants have been secured and

their positions veried radiographically, the formal fusion procedure is performed.
Autologous bone graft obtained from the iliac
crest has the advantages of easy availability,
moderate cost, osteogenic potential, and no risk
of disease transmission. Corticocancellous strips
harvested from the lateral ilium are ideal to place
across osteotomy sites. Cancellous bone also is
harvested and is the main graft material, along
with bone obtained from the facetectomies and
any osteotomies.
The dorsal bony elements are decorticated with
a high-speed round burr. An eort is made to
preserve the bone dust generated by the burr.
Small amounts of sterile irrigation are used to
prevent the burr from becoming hot and burning
the bone. Spinous processes may be harvested for
additional bone graft. In extremely thin patients,
however, doing so may lead to signicant implant
prominence. Bone graft is placed over the decorticated surfaces. Various synthetic and allogeneic
graft extenders are available to increase the
volume and improve the handling characteristics
of the graft. Such products may dilute the
osteogenic potential of the graft, however. The
surgeon also may choose to use biologic arthrodesis enhancers in a manner not approved by the
Food and Drug Administration to increase the
likelihood of obtaining a solid fusion, particularly
in patients with pseudarthrosis.


including CT scans, and exploration for implant

removal or adjustment of the correction.
Patients may not require a stay in the ICU
postoperatively, but should be observed by nursing and ancillary sta familiar with complex
spinal surgery. Laboratory studies, particularly
blood counts and routine chemistries, should be
monitored for at least the rst 3 days after
surgery. Blood transfusions should be given based
on the patients age and medical status. While
drains are in place and actively draining, low
blood counts should be anticipated and transfusions given before dangerous levels are reached.
With secure segmental xation, it is often safe
to allow a patient to place axial loads on the spine
on postoperative day 1 [3]. If a brace is deemed
necessary, measurements should be taken in
the operating room or early in the postoperative
period to facilitate early mobilization. Patients
are encouraged to sit and stand on the morning
after surgery. The physical therapy service should
be involved from the rst postoperative day to ensure the use of proper techniques for getting out
of bed and appropriate sitting and standing

The postoperative care of the patient begins in
the operating room. Procedures to correct sagittal
imbalance are often long and involve signicant
blood loss and large volumes of intravenous uid
and blood and blood products. The patient may
have signicant facial and laryngeal swelling. In
these circumstances, it may be advisable for patient
safety and comfort to keep the patient intubated
overnight to allow diuresis before extubation.
Whether the patient is extubated in the operating room or not, he or she should be awakened
suciently to perform a comprehensive neurologic examination. Particularly after the closure of
a lumbar PSO, individual myotome function
should be carefully examined bilaterally. Any
new decit should be investigated expeditiously
and treated appropriately, which may include
obtaining additional radiographic studies,

Fig. 9. Patient who underwent a previous lumbarinstrumented fusion. (A) Global (type II) sagittal imbalance developed as a result of a combination of
proximal and distal adjacent segment degeneration. (B)
Circumferential surgery consisting of extension of the
posterior instrumentation and fusion and an anterior
L5-S1 diskectomy and interbody fusion restored her
lumbar lordosis and overall sagittal balance.



Fig. 10. Lateral postoperative radiograph shows proximal adjacent segment degeneration. Supine (A) and upright lateral (B) radiographs show the unstable/hypermobile spondylolisthesis at T9-10 proximal to instrumented construct.

Patient-controlled analgesia with parenteral

opiates is maintained until approximately postoperative day 3. Typically, patients receive a continuous infusion and a demand dose. When the
postoperative ileus begins to resolve, manifest by
the passing of atus, the weaning of intravenous
medication is begun. To smooth the transition to
oral analgesics, the basal rate is discontinued rst
and replaced with long-acting oral narcotics. The
following day the demand dose is discontinued or
signicantly reduced, and short-acting oral narcotics are given for breakthrough pain.
Subfascial and supercial drains are left in
until at least postoperative day 3. Baseline postoperative radiographs (upright anteroposterior
and lateral long-cassette) are taken when the
patient is able to walk with minimal diculty,
typically postoperative day 5 or after. Radiographs obtained before a patient can stand
without support are unsatisfactory.
Loss of correction in the sagittal plane may
occur and can be the result of a few developments.
First, distal or proximal implant failure may lead
to sudden or gradual loss of correction. Standing
anteroposterior and lateral radiographs should be
obtained before discharging the patient from the
hospital and at regular intervals during the
postoperative period. These should be inspected
carefully for evidence of implant integrity and
Proximal or distal adjacent segment degeneration also may result in worsening of sagittal
balance over time (Fig. 9). Regions of the spine
that were not included in the construct and

arthrodesis should be examined on follow-up radiographs for signs of degeneration and progressive kyphosis. Attention should be paid to the
upper instrumented vertebra and the level immediately proximal to it to ensure that the regional
alignment is unchanged from previous radiographs (Fig. 10). A brief history and physical examination should be directed toward detecting
signs or symptoms of loss of correction or neural
compression in adjacent segments.
Sagittal imbalance may cause signicant pain
and functional limitations for patients. Successful
surgical treatment of sagittal plane deformities
can result in a signicant improvement in quality
of life for the patient. These complex procedures
may be associated with a relatively high rate of
complications. Careful planning, meticulous surgical technique, and vigilant postoperative followup may help to minimize the occurrence of
complications and optimize patient outcomes.
[1] Bernhardt M, Bridwell KH. Segmental analysis of
the sagittal plane alignment of the normal thoracic
and lumbar spines and thoracolumbar junction.
Spine 1989;14:71721.
[2] Gelb DE, Lenke LG, Bridwell KH, et al. An analysis
of sagittal spinal alignment in 100 asymptomatic
middle and older aged volunteers. Spine 1995;20:
[3] Booth KC, Bridwell KH, Lenke LG, et al. Complications and predictive factors for the successful
treatment of atback deformity (xed sagittal imbalance). Spine 1999;24:171220.


[4] Lagrone MO, Bradford DS, Moe JH, et al. Treatment of symptomatic atback after spinal fusion.
J Bone Joint Surg Am 1988;70:56980.
[5] Bridwell KH, Lenke LG, Lewis SJ. Treatment of spinal stenosis and xed sagittal imbalance. Clin
Orthop 2001;384:3544.
[6] Glassman SD, Bridwell KH, Dimar JR, et al. The
impact of positive sagittal balance in adult spinal deformity. Spine 2005;30:20249.
[7] Berven SH, Deviren V, Smith JA, et al. Management
of xed sagittal plane deformity: outcome of combined anterior and posterior surgery. Spine 2003;
[8] Edwards CC 2nd, Bridwell KH, Patel A, et al. Thoracolumbar deformity arthrodesis to L5 in adults: the
fate of the L5S1 disc. Spine 2003;28:212231.
[9] Smith-Peterson MN, Larson CB, Aufranc OE.
Osteotomy of the spine for the correction of deformity in rheumatoid arthritis. J Bone Joint Surg Am
[10] Van Royen BJ, Slot GH. Closing-wedge posterior
osteotomy for ankylosing spondylitis: partial corpectomy and transpedicular xation in 32 cases.
J Bone Joint Surg Br 1995;77:11721.


[11] Bridwell KH, Lewis SJ, Rinella A, et al. Pedicle

subtraction osteotomy for the treatment of xed sagittal imbalance. J Bone Joint Surg Am 2004;
86(Suppl 1):4450.
[12] Berven SH, Deviren V, Smith JA, et al. Management
of xed sagittal plane deformity: results of the
transpedicular wedge resection osteotomy. Spine
[13] Kim KT, Suk KS, Cho YJ, et al. Clinical outcome
results of pedicle subtraction osteotomy in ankylosing spondylitis with kyphotic deformity. Spine 2002;
[14] Potter BK, Lenke LG, Kuklo TR. Prevention and
management of iatrogenic atback deformity.
J Bone Joint Surg Am 2004;86:1793808.
[15] Cho K-J, Bridwell KH, Lenke LG, et al. Comparison of Smith-Petersen versus pedicle subtraction
osteotomy for the correction of xed sagittal imbalance. Spine 2005;30:20307.
[16] Bridwell KH, Lenke LG, Baldus C, et al. Major
intraoperative neurologic decits in pediatric
and adult spinal deformity patients: incidence
and etiology at one institution. Spine 1998;23: