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Sagittal Balance of the Spine

From Normal to Pathology: A Key for Treatment Strategy

Pierre Roussouly, MD
Senior Surgeon
Spinal Surgery Unit
Croix Rouge Française-CMCR des Massues
Lyon, France

João Luiz Pinheiro-Franco, MD, AFS

Neurosurgeon and Spine Surgeon

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Samaritano Hospital of São Paulo
São Paulo, Brazil

Hubert Labelle, MD
Professor of Surgery
Division of Orthopedic Surgery
University of Montreal
Montréal, Québec, Canada

Martin Gehrchen, MD, PhD

Associate Professor and Head of Spine Surgery
Spine Unit
Department of Orthopaedic Surgery
Rigshospitalet and University of Copenhagen
Copenhagen, Denmark

259 illustrations

Thieme
New York • Stuttgart • Delhi • Rio de Janeiro
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Executive Editor: Timothy J. Hiscock Important note: Medicine is an ever-changing science undergoing
Managing Editor: Sarah Landis continual development. Research and clinical experience are con-
Director, Editorial Services: Mary Jo Casey tinually expanding our knowledge, in particular our knowledge of
Production Editors: Naamah Schwartz and Torsten Scheihagen proper treatment and drug therapy. Insofar as this book mentions
International Production Director: Andreas Schabert any dosage or application, readers may rest assured that the
Editorial Director: Sue Hodgson authors, editors, and publishers have made every effort to ensure
International Marketing Director: Fiona Henderson that such references are in accordance with the state of knowledge
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Director of Institutional Sales: Adam Bernacki Nevertheless, this does not involve, imply, or express any guar-
Senior Vice President and Chief Operating Officer: Sarah Vanderbilt antee or responsibility on the part of the publishers in respect to any
President: Brian D. Scanlan dosage instructions and forms of applications stated in the book.
Printer: King Printing Co., Inc. Every user is requested to examine carefully the manufacturers’
leaflets accompanying each drug and to check, if necessary in
Library of Congress Cataloging-in-Publication Data consultation with a physician or specialist, whether the dosage
schedules mentioned therein or the contraindications stated by
Names: Roussouly, Pierre, editor. | Pinheiro-Franco, João Luiz, editor. |
the manufacturers differ from the statements made in the present
Labelle, Hubert, editor. | Gehrchen, Martin, editor.
book. Such examination is particularly important with drugs that
Title: Sagittal balance of the spine : from normal to pathology : a key for
are either rarely used or have been newly released on the market.
treatment strategy / [edited by] Pierre Roussouly, João Luiz
Every dosage schedule or every form of application used is entirely
Pinheiro-Franco, Hubert Labelle, Martin Gehrchen.
at the user’s own risk and responsibility. The authors and publishers
Description: New York : Thieme, [2019] | Includes bibliographical
request every user to report to the publishers any discrepancies or
references.
inaccuracies noticed. If errors in this work are found after publica-
Identifiers: LCCN 2019010292| ISBN 9781626237322 (hardback) |
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ISBN 9781626237339 (e-book)
description page.
Subjects: | MESH: Spinal Curvatures–physiopathology | Spinal
Some of the product names, patents, and registered designs
Curvatures–surgery | Spine–surgery | Spine–physiology | Postural
referred to in this book are in fact registered trademarks or pro-
Balance–physiology | Spondylolisthesis
prietary names even though specific reference to this fact is not
Classification: LCC RD768 | NLM WE 735 | DDC 617.4/71–dc23 LC
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© 2019 by Thieme Medical Publishers, Inc.

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Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

I Introduction to Sagittal Balance

1. Historical Background of Spinal Sagittal Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Pierre Roussouly and Nishant Nishant

2. The Acquisition of Human Verticality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Christine Tardieu and Martin Haeusler

II Biomechanics of Sagittal Balance

3. From the Head to the Feet: Anatomy of the Upright Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

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Jean Marc Vital, Jacques Sénégas, and Jean-Etienne Castelain

4. Modeling of the Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Carl-Eric Aubin and Xiaoyu Wang

5. Sagittal Balance: The Main Parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

João Luiz Pinheiro-Franco and Pierre Roussouly

6. Spinal Curves Segmentation and Lumbar Lordosis Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Amer Sebaaly and Pierre Roussouly

III Normative Values Following Age and Populations

7. Normative Values of Sagittal Balance in Children and Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Jean-Marc Mac-Thiong and Fethi Laouissat

8. Sagittal Balance in the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

Martin Gehrchen

IV The Sagittal Balance of the Spine in Pathology

9. Local Stresses: Segmental Mechanism of Low Back Pain and Degeneration,
and Stresses According to Spinal Orientation—Contact Forces Theory . . . . . . . . . . . . . . . . . . . . . . . 88
Amer Sebaaly, João Luiz Pinheiro-Franco, and Pierre Roussouly

10. Mechanisms of Spinal Degeneration According to Spinopelvic Morphotypes . . . . . . . . . . . . . . . 96

João Luiz Pinheiro-Franco and Pierre Roussouly

11. Sagittal Imbalance Compensatory Mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Martin Gehrchen

v
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Contents

V The Non Scoliotic Spine

12. Isthmic Lytic Spondylolisthesis—The Physiopathology, Classification, and Treatment
Better Explained by the Sagittal Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Hubert Labelle, Jean-Marc Mac-Thiong, Stefan Parent, and Pierre Roussouly

13. Degenerative Spondylolisthesis: Does the Sagittal Balance Matter? . . . . . . . . . . . . . . . . . . . . . . . . . . 134

Cédric Y. Barrey, Charles Peltier, Amir El Rahal, Théo Broussolle, and Pierre Roussouly

14. The Degenerative Aging Spine: A Challenge for Contemporaneous Societies . . . . . . . . . . . . . . . . 146
Jean-Charles Le Huec, Wendy Thompson, Amélie Leglise, Marion Petit, and Thibault Cloché

15. Scheuermann’s Kyphosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

Stefan Parent, Abdulmajeed Alzakri, and Hubert Labelle

16. Cervical Sagittal Alignment and Cervicarthrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

Darryl Lau and Christopher P. Ames

17. Advantages and Limitations of the SRS-Schwab Classification for

Adult Spinal Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Hideyuki Arima, Leah Y. Carreon, and Steven D. Glassman

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VI Adolescent Idiopathic Scoliosis (AIS)
18. Specificities in Growing Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Shahnawaz Haleem and Colin Nnadi

19. Sagittal Balance Incidence on Treatment Strategy in AIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

Stefan Parent

VII Adult Scoliosis (AS)

20. From Pathological to Normal Shapes in Adult Scoliosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Pierre Roussouly and Amer Sebaaly

21. Sagittal Balance Treatment Strategy in a Posterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204

Fethi Laouissat and Pierre Roussouly

22. Adult Scoliosis Treatment with an Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

Anthony M. DiGiorgio, Mohanad Alazzeh, and Praveen V. Mummaneni

23. Techniques for Spine Osteotomies and Clinical Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

Ibrahim Obeid and Derek T. Cawley

24. Surgical Failures Mechanisms and Their Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228

Pierre Roussouly, Hyoungmin Kim, Amer Sebaaly, and Daniel Chopin

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240

vi
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Foreword
What is balance? negative compensations. What we call harmony is the best
This question may first appear to all of us evident: how sagittal shape allowing an ideal muscle action. Gravity, spinal
could we stand, sit, or walk properly without balance? shape, and muscles are the three main components working
Artists must have an intimate sense or feeling of balance together to achieve good balance. However, even if
in order to master the main law of beauty: harmony. For us simplified, it is impossible to standardize the human body
spine surgeons, a few years ago, our only means to evaluate balance and any attempt to do so is bound to fail.
post-operative balance was to observe a match between Despite important progress, we must keep in mind that
good functional result and good-looking, harmonious pro- this book is mainly based on static studies. Dynamic anal-
file restoration. This intuitive feeling, even if efficient in yses are currently missing but should not be forgotten.
some hands, was difficult to explain and transmit. We hope that even if the aesthetic point of view remains
It is only with the routine use of long-standing lateral important, a better scientific approach will help spine
X-rays that we became able to describe sagittal balance surgeons provide more appropriate treatment of spinal
parameters. Hundreds of discussions, sometimes heated, deformities.
allowed for a better scientific approach. This book is a
cornerstone of what we have progressively understood in Daniel Chopin, MD
the last few years with our successes and failures. (retired)
If the principle of harmony is unique to the individual, Spinal Unit

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everyone also has his own answer to find balance according Neuro-Orthopedic Department
to his own characteristics: shape, muscle strength, age. Grav- University of Lille, France
ity imposes inescapable forces of control on the human body. Spine Center
A good profile is the one which minimizes muscle action and Institut Calot Berck sur Mer, France

vii
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Preface
In 1998, when Duval-Beaupère published a new pelvic Balancing between flexion and extension stresses, each
parameter, the pelvic incidence, and demonstrated its influ- type develops its own degenerative evolution resulting in
ence on the spinal shape, sagittal balance was not a very hot specific degenerative shapes following PI and compensation
topic as only five publications had addressed this specific ability.
subject in the international literature. By comparison, in the Various parameter combinations have been described to
past two years more than two hundred publications have characterize a balanced or unbalanced status, but they are
approached the subject. This underlines the importance of focused on L1-S1 lumbar lordosis and pelvic parameters.
sagittal balance evaluation in the daily practice of a spinal This is insufficient to determine a treatment strategy, since
specialist today. it ignores PI specificities and spinal curvature reciprocity.
Even if pelvic and spinal parameters and their combina- Even if it is well known that an unbalanced result induces a
tion organizing sagittal body alignment are well defined, the bad functional result, it is still not well understood what a
use of this knowledge in understanding spinal pathology balanced system is and how to reach it.
and developing treatment strategies remains uncertain, and In order to settle the concept “from normal to pathology,”
practitioners continue to face unexpected treatment we need to reverse the approach and address “from pathol-
failures. ogy to normal.” In a pathology, we have evidence of the
In this book, we have tried to develop a global concept: previous “normal” status using PI that may offer guidance
“from normal to pathology.” Of course, it is impossible to for how to restore an appropriate shape. Following PI values,

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define “normal” because of the wide range of a normal we may anticipate the better “normal” shape fitting with the
status; for humans, normality is the fantastic property of pelvis specificity. It is not just a matter of angle restitution,
permanent verticality acquired with evolution. The human since curve repartition has to be respected to avoid mechan-
body is the only one able to sustain the standing position ical failures such as PJK.
with a balanced and economical status. Anatomical evolu- The reader will observe that this book is not based on
tion of the pelvic shape is the mechanical key of verticality, technical descriptions. Our aim was to emphasize the treat-
changing from flat and high in the first tree-dwelling pri- ment strategy following spinopelvic shape identification. It
mates to large and retroverted in humans. This heredity was a difficult challenge: some assertions are still hypo-
explains the large range of pelvic shapes characterized by thetical and will have to be demonstrated in future studies.
the pelvic incidence angle (PI). The strong relation between As a global concept, we have tried to define each step of
spinal shape and the sacral plateau allowed for the devel- sagittal balance evolution during life and following each
opment of a classification of normal spinopelvic alignment shape specificity. Probably as the basis of treatment strat-
related to PI values. These different spinal shapes deriving egy, it would have been too ambitious to use this shortcut as
from PI variation demonstrate their own mechanical a title: “How to return to normal from normal.” We hope
behavior. that this book will help you in understanding the fascinating
In young adults, every type of sagittal alignment is able to story of sagittal balance.
provide an economical system, but with increasing age and
stress, degeneration can occur and progressively changes Pierre Roussouly, MD
alignment orientation and balance features. To maintain João Luiz Pinheiro-Franco, MD, AFS
verticality, the human body has to develop compensatory Hubert Labelle, MD
mechanisms, and loses the initial economic status. Martin Gehrchen, MD, PhD

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Contributors
Mohanad Alazzeh, BS Leah Y. Carreon, MD, MSc
Department of Neurosurgery Clinical Research Director
University of California at San Francisco Norton Leatherman Spine Center
San Francisco, California, USA Louisville, Kentucky, USA

Abdulmajeed Alzakri, MD, MS, DESC Ortho Jean-Etienne Castelain, MD

Clinical Spine Surgery Fellow at the University Fellowship
of Montréal Department of Orthopaedics and Traumatology
Department of Orthopaedics Spine Unit 1
College of Medicine, King Saud University University Hospital of Bordeaux,
Riyadh, Saudi Arabia Bordeaux, Aquitaine, France

Christopher P. Ames, MD Derek T. Cawley, MMedSc, MCh, FRCS

Professor Consultant Spine Surgeon
Department of Neurological Surgery Tallaght University Hospital
University of California, San Francisco Dublin, Republic of Ireland
San Francisco, California, USA

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Daniel Chopin, MD
Hideyuki Arima, MD, PhD (retired)
Research Fellow Spinal Unit
Department of Orthopaedic Surgery Neuro-Orthopedic Department
Norton Leatherman Spine Center University of Lille, France
Louisville, Kentucky, USA Spine Center
Clinical Instructor Institut Calot Berck sur Mer, France
Department of Orthopaedic Surgery
Hamamatsu University School of Medicine Thibault Cloché, MD
Hamamatsu, Shizuoka, Japan Orthospine Department
Bordeaux Nord Aquitaine Hospital
Carl-Eric Aubin, PhD, ScD (hc), PEng Bordeaux University
Professor Bordeaux, Nouvelle Aquitaine, France
Department of Mechanical Engineering
Polytechnique Montreal Anthony M. DiGiorgio, DO, MHA
Researcher Resident
Sainte-Justine University Hospital Center Department of Neurosurgery
Montréal, Québec, Canada Louisiana State University Health Sciences Center
New Orleans, Louisiana, USA
Cédric Y. Barrey, MD, PhD
Chairman Amir El Rahal, MD
Department of Spine and Spinal Cord Surgery Department of Neurosurgery
Hôpital Pierre Wertheimer University Hospital of Geneva, HUG
Hospices Civils de Lyon Geneva, Switzerland
Université Claude Bernard Lyon 1
Lyon, France Martin Gehrchen, MD, PhD
Associate Professor and Head of Spine Surgery
Théo Broussolle Spine Unit
Surgical Specialty Intern Department of Orthopaedic Surgery
Department of Neurosurgery C Rigshospitalet and University of Copenhagen
Neurological Hospital Copenhagen, Denmark
Lyon, France

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Contributors

Steven D. Glassman, MD Jean-Charles Le Huec, MD, PhD

Professor Professor
Department of Orthopedic Surgery Department of Orthospine
University of Louisville Bordeaux Nord Aquitaine Hospital
Louisville, Kentucky, USA Bordeaux University
Bordeaux, Nouvelle Aquitaine, France
Martin Haeusler, PhD
Head Evolutionary Morphology and Adaptation Group Praveen V. Mummaneni, MD
Institute of Evolutionary Medicine Joan O'Reilly Endowed Professor in Spinal Surgery
University of Zurich Vice Chairman
Zurich, Switzerland Deptartment of Neurosurgery
University of California, San Francisco
Shahnawaz Haleem, MSc(Tr&Orth), MRCSEd, MRCSI, San Francisco, California, USA
FRCS(Tr&Orth)
Complex Spine Fellow Nishant Nishant, MD
Honorary Associate Clinical Lecturer Orthopedic and Spine Surgeon
St. George's University Hospital Rameshwaram Orthopedic
Oxford University Hospitals Spine & Ent Clinic
London, United Kingdom Patna, Bihar, India

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Hyoungmin Kim, MD, PhD Colin Nnadi, MBBS, FRCS(Orth)
Clinical Associate Professor Spine Unit
Department of Orthopedic Surgery Oxford University Hospitals NHS Foundation Trust
Seoul National University Hospital Oxford, Oxfordshire, United Kingdom
Seoul, South Korea
Ibrahim Obeid, MD, MSc
Hubert Labelle, MD Consultant
Professor of Surgery Spine Department
Division of Orthopedic Surgery Bordeaux University
University of Montreal Bordeaux, France
Montréal, Québec, Canada
Stefan Parent, MD, PhD
Fethi Laouissat, MD Full Professor of Surgery
Consultant Orthopaedic Surgeon Chair, Academic Chair in Pediatric Spinal Deformities of CHU
Spine Surgery Unit Ste-Justine
Hôpital Privé de l’Est Lyonnais Chief, Division of Pediatric Orthopedic Surgery
Saint-Priest, Rhône, France CHU Sainte-Justine
Department of Surgery
Darryl Lau, MD Université de Montréal
Chief Resident Montréal, Québec, Canada
Department of Neurological Surgery
University of California, San Francisco Charles Peltier, MD
San Francisco, California, USA Department of Spine Surgery
Hôpital P.-Wertheimer, Hospices Civils de Lyon
Amélie Leglise, MD Lyon, France
Orthopédie Department
Bordeaux Pellegrin Hospital Marion Petit, MD
Bordeaux University Orthopédie Department
Bordeaux, Nouvelle Aquitaine, France Bordeaux Pellegrin Hospital, Bordeaux University
Bordeaux, Nouvelle Aquitaine, France

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Contributors

João Luiz Pinheiro-Franco, MD, AFS Jean-Marc Mac-Thiong, MD, PhD

Neurosurgeon and Spine Surgeon Associate Professor
Samaritano Hospital of São Paulo Department of Surgery
São Paulo, Brazil Université de Montréal
Montréal, Québec, Canada
Pierre Roussouly, MD
Senior Surgeon Wendy Thompson, MD
Spinal Surgery Unit Orthospine Department
Croix Rouge Française-CMCR des Massues Bordeaux Nord Aquitaine Hospital, Bordeaux University
Lyon, France Bordeaux, Nouvelle Aquitaine, France

Amer Sebaaly, MD, BS Jean Marc Vital, MD, PhD

Department of Orthopedic Surgery Spinal Unit
Hotel Dieu de France Hospital Universitary Hospital Pellegrin
Saint Joseph University Bordeaux, France
Beirut, Lebanon
Xiaoyu Wang, PhD
Jacques Sénégas, MD Research Fellow
Spine Surgeon Department of Mechanical Engineering
Professor Polytechnique Montreal

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Département of Anatomy Montréal, Québec, Canada
University Bordeaux II
Bordeaux, France

Christine Tardieu, PhD

Director of Research CNRS
Research Unit “Adaptativ Mecanisms and Evolution”
Department “Adaptation du Vivant”
National Museum of Natural History
Paris, France

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