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European Spine Journal

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01-08-2018 | Original Article

Classification of normal sagittal spine alignment: refounding the Roussouly classification

Authors: Féthi Laouissat, Amer Sebaaly, Martin Gehrchen, Pierre Roussouly

Published in: European Spine Journal | Issue 8/2018

Abstract

Purpose

Although the Roussouly classification of common variants in spinal sagittal alignment is well accepted, no studies have implemented it in an asymptomatic adult population. In addition, no study investigated the radiographic features of asymptomatic patients with an anteverted pelvis. The aim of this prospective radiographic study of 296 asymptomatic adults without spinal pathology was to investigate how the Roussouly classification could include the anteverted pelvis concept.

Methods

Pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), and the lumbar parameters lumbar lordosis (Global LL), lordosis tilt angle (LTA), total number of lordotic vertebra (LL verteb), and C7 plumbline/sacrofemoral distance ratio (C7PL ratio) were evaluated in 296 healthy volunteers (126 males, 170 females; mean age, 27 years; range 18–48 years). Comparison between the five types of the Roussouly classification used Student, ANOVA, and Tukey tests for quantitative variables and χ ², Fischer, and Holm tests for qualitative variables.

Results

Mean PI and PT were, respectively, (39°, 10°) for type 1, (41°, 10°) for type 2, (53°, 13°) for type 3, and (62°, 12°) for type 4 (p < 0.0001 and p < 0.01). A sizable portion (16%) of the population (type 3 AP) showed low-grade PI (mean, 48° ± 6°) despite having SS > 35°. PT was low or negative (mean 4° ± 3°). C7PL ratio was >1 (in front of the hip axis) in 13% of all cases, and between 0 and 1 (between sacrum and hip axis) in 49%.

Conclusion

Although asymptomatic adults stood with stable global balance, the sagittal spinal alignment of healthy subjects, newly divided in 5 sagittal types, varied significantly. Type 3 AP appears as a new and unusual sagittal shape with low-grade PI, very low or negative PT, and hyperlordosis. Whereas most asymptomatic adults stood with C7PL behind the hip axis, a sizeable portion had C7 in front of the hip axis. This could be a new controversial aspect of ideal spinal balance.

Berthonnaud E, Dimnet J, Roussouly P, Labelle H (2005) Analysis of the sagittal balance of the spine and pelvis using shape and orientation parameters. J Spinal Disord Tech 18(1):40–47CrossRefPubMed

During J, Goudfrooij H, Keessen W, Beeker TW, Crowe A (1985) Toward standards for posture. Postural characteristics of the lower back system in normal and pathologic conditions. Spine 10(1):83–87CrossRefPubMed

Mac-Thiong JM, Roussouly P, Berthonnaud E, Guigui P (2010) Sagittal parameters of global spinal balance: normative values from a prospective cohort of seven hundred nine Caucasian asymptomatic adults. Spine 35(22):E1193–E1198. doi:10.1097/BRS.0b013e3181e50808 CrossRefPubMed

Mac-Thiong JM, Roussouly P, Berthonnaud E, Guigui P (2011) Age- and sex-related variations in sagittal sacropelvic morphology and balance in asymptomatic adults. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 20(Suppl 5):572–577. doi:10.1007/s00586-011-1923-2 CrossRef

Roussouly P, Gollogly S, Berthonnaud E, Dimnet J (2005) Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine 30(3):346–353CrossRefPubMed

Roussouly P, Gollogly S, Noseda O, Berthonnaud E, Dimnet J (2006) The vertical projection of the sum of the ground reactive forces of a standing patient is not the same as the C7 plumb line: a radiographic study of the sagittal alignment of 153 asymptomatic volunteers. Spine 31(11):E320–E325. doi:10.1097/01.brs.0000218263.58642.ff CrossRefPubMed

Legaye J, Duval-Beaupere G, Hecquet J, Marty C (1998) Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 7(2):99–103CrossRef

Schwab F, Lafage V, Patel A, Farcy JP (2009) Sagittal plane considerations and the pelvis in the adult patient. Spine 34(17):1828–1833. doi:10.1097/BRS.0b013e3181a13c08 CrossRefPubMed

Marks M, Stanford C, Newton P (2009) Which lateral radiographic positioning technique provides the most reliable and functional representation of a patient’s sagittal balance? Spine 34(9):949–954. doi:10.1097/BRS.0b013e318199650a CrossRefPubMed

10.

Barrey C, Roussouly P, Perrin G, Le Huec JC (2011) Sagittal balance disorders in severe degenerative spine. Can we identify the compensatory mechanisms? Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 20(Suppl 5):626–633. doi:10.1007/s00586-011-1930-3 CrossRef

11.

Berthonnaud E, Labelle H, Roussouly P, Grimard G, Vaz G, Dimnet J (2005) A variability study of computerized sagittal spinopelvic radiologic measurements of trunk balance. J Spinal Disord Tech 18(1):66–71CrossRefPubMed

12.

Vaz G, Roussouly P, Berthonnaud E, Dimnet J (2002) Sagittal morphology and equilibrium of pelvis and spine. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 11(1):80–87CrossRef

13.

Maillot C, Ferrero E, Fort D, Heyberger C, Le Huec JC (2015) Reproducibility and repeatability of a new computerized software for sagittal spinopelvic and scoliosis curvature radiologic measurements: Keops((R)). Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 24(7):1574–1581. doi:10.1007/s00586-015-3817-1 CrossRef

14.

Ferrero E, Vira S, Ames CP, Kebaish K, Obeid I, O’Brien MF, Gupta MC, Boachie-Adjei O, Smith JS, Mundis GM, Challier V, Protopsaltis TS, Schwab FJ, Lafage V, International Spine Study G (2015) Analysis of an unexplored group of sagittal deformity patients: low pelvic tilt despite positive sagittal malalignment. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc. doi:10.1007/s00586-015-4048-1 CrossRef

15.

Mac-Thiong JM, Labelle H, Roussouly P (2011) Pediatric sagittal alignment. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 20(Suppl 5):586–590. doi:10.1007/s00586-011-1925-0 CrossRef

16.

Inami S, Moridaira H, Takeuchi D, Shiba Y, Nohara Y, Taneichi H (2016) Optimum pelvic incidence minus lumbar lordosis value can be determined by individual pelvic incidence. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc. doi:10.1007/s00586-016-4563-8 CrossRef

17.

Janusz P, Tyrakowski M, Monsef JB, Siemionow K (2016) Influence of lower limbs discrepancy and pelvic coronal rotation on pelvic incidence, pelvic tilt and sacral slope. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc. doi:10.1007/s00586-016-4458-8 CrossRef

18.

Vrtovec T, Janssen MM, Pernus F, Castelein RM, Viergever MA (2012) Analysis of pelvic incidence from 3-dimensional images of a normal population. Spine 37(8):E479–E485. doi:10.1097/BRS.0b013e31823770af CrossRefPubMed

19.

Weinberg DS, Morris WZ, Gebhart JJ, Liu RW (2015) Pelvic incidence: an anatomic investigation of 880 cadaveric specimens. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc. doi:10.1007/s00586-015-4317-z CrossRef

20.

Schwab F, Lafage V, Boyce R, Skalli W, Farcy JP (2006) Gravity line analysis in adult volunteers: age-related correlation with spinal parameters, pelvic parameters, and foot position. Spine 31(25):E959–E967. doi:10.1097/01.brs.0000248126.96737.0f CrossRefPubMed

21.

Vialle R, Levassor N, Rillardon L, Templier A, Skalli W, Guigui P (2005) Radiographic analysis of the sagittal alignment and balance of the spine in asymptomatic subjects. J Bone Jt Surg Am 87(2):260–267. doi:10.2106/JBJS.D.02043 CrossRef

22.

Stagnara P, De Mauroy JC, Dran G, Gonon GP, Costanzo G, Dimnet J, Pasquet A (1982) Reciprocal angulation of vertebral bodies in a sagittal plane: approach to references for the evaluation of kyphosis and lordosis. Spine 7(4):335–342CrossRefPubMed

23.

Matsuyama Y, Hasegawa Y, Yoshihara H, Tsuji T, Sakai Y, Nakamura H, Kawakami N, Kanemura T, Yukawa Y, Ishiguro N (2004) Hip-spine syndrome: total sagittal alignment of the spine and clinical symptoms in patients with bilateral congenital hip dislocation. Spine 29(21):2432–2437CrossRefPubMed

24.

Yoshimoto H, Sato S, Masuda T, Kanno T, Shundo M, Hyakumachi T, Yanagibashi Y (2005) Spinopelvic alignment in patients with osteoarthrosis of the hip: a radiographic comparison to patients with low back pain. Spine 30(14):1650–1657CrossRefPubMed

Title: Classification of normal sagittal spine alignment: refounding the Roussouly classification
Authors: Féthi Laouissat
Amer Sebaaly
Martin Gehrchen
Pierre Roussouly
Publication date: 01-08-2018
Publisher: Springer Berlin Heidelberg
Published in: European Spine Journal / Issue 8/2018
Print ISSN: 0940-6719
Electronic ISSN: 1432-0932
DOI: https://doi.org/10.1007/s00586-017-5111-x

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Classification of normal sagittal spine alignment: refounding the Roussouly classification

Abstract

Purpose

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

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