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The Impact of Positive Sagittal Balance in Adult Spinal Deformity

Glassman, Steven D., MD*; Bridwell, Keith, MD; Dimar, John R., MD*; Horton, William, MD§; Berven, Sigurd, MD; Schwab, Frank, MD

doi: 10.1097/01.brs.0000179086.30449.96
Clinical Case Series

Study Design. This study is a retrospective review of 752 patients with adult spinal deformity enrolled in a multicenter prospective database in 2002 and 2003. Patients with positive sagittal balance (N = 352) were further evaluated regarding radiographic parameters and health status measures, including the Scoliosis Research Society patient questionnaire, MOS short form-12, and Oswestry Disability Index.

Objectives. To examine patients with adult deformity with positive sagittal balance to define parameters within that group that might differentially predict clinical impact.

Summary of Background Data. In a multicenter study of 298 adults with spinal deformity, positive sagittal balance was identified as the radiographic parameter most highly correlated with adverse health status outcomes.

Methods. Radiographic evaluation was performed according to a standarized protocol for 36-inch standing radiographs. Magnitude of positive sagittal balance and regional sagittal Cobb angle measures were recorded. Statistical correlation between radiographic parameters and health status measures were performed. Potentially confounding variables were assessed.

Results. Positive sagittal balance was identified in 352 patients. The C7 plumb line deviation ranged from 1 to 271 mm. All measures of health status showed significantly poorer scores as C7 plumb line deviation increased. Patients with relative kyphosis in the lumbar region had significantly more disability than patients with normal or lordotic lumbar sagittal Cobb measures.

Conclusions. This study shows that although even mildly positive sagittal balance is somewhat detrimental, severity of symptoms increases in a linear fashion with progressive sagittal imbalance. The results also show that kyphosis is more favorable in the upper thoracic region but very poorly tolerated in the lumbar spine.

This study examines 352 patients with adult deformity with positive sagittal balance. Although even mildly positive sagittal balance is somewhat detrimental, severity of symptoms was noted to increase in a linear fashion with progressive sagittal imbalance.

From the Departments of Orthopaedic Surgery, *University of Louisville School of Medicine and the Kenton D. Leatherman Spine Center, Louisville, KY; †University of California, San Francisco, CA; ‡Washington University, St. Louis, MO; §Emory University, Atlanta, GA; and ∥NYU Hospital for Joint Disease, New York, NY.

Acknowledgment date: October 6, 2004. First revision date: January 26, 2005. Acceptance date: January 27, 2005.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Corporate/Industry funds were received in support of this work. Although one or more of the authors(s) has/have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this manuscript, benefits will be directed solely to a research fund, foundation, educational institution, or other nonprofit organization which the author(s) has/have been associated.

Address correspondence and reprint requests to Steven D. Glassman, MD, Spine Institute, Suite 900, 210 E. Gray Street, Louisville KY 40202; E-mail:

© 2005 Lippincott Williams & Wilkins, Inc.