SPINE Volume 35, Number 25, pp 2224 –2231
©2010, Lippincott Williams & Wilkins
Adult Spinal Deformity—Postoperative
Standing Imbalance
How Much Can You Tolerate? An Overview of Key Parameters in
Assessing Alignment and Planning Corrective Surgery
Frank Schwab, MD, Ashish Patel, MD, Benjamin Ungar, BA, Jean-Pierre Farcy, MD,
and Virginie Lafage, PhD
Study Design. Current concepts review.
Objective. Outline the basic principles in the evalua-
tion and treatment of adult spinal deformity patients with
a focus on goals to achieve during surgical realignment
surgery.
Summary of Background Data. Proper global align-
ment of the spine is critical in maintaining standing pos-
ture and balance in an efficient and pain-free manner.
Outcomes data demonstrate the clinical effect of spi-
nopelvic malalignment and form a basis for realignment
strategies.
Methods. Correlation between certain radiographic
parameters and patient self-reported pain and disability
has been established. Using normative values for several
important spinopelvic parameters (including sagittal ver-
tical axis, pelvic tilt, and lumbar lordosis), spinopelvic
radiographic realignment objectives were identified as a
tool for clinical application. Because of the complex rela-
tionship between the spine and the pelvis in maintaining
posture and the wide range of “normal” values for the
associated parameters, a focus on global alignment, with
proportionality of individual parameters to each other,
was pursued to provide clinical relevance to planning
realignment for deformity across a range of clinical cases.
Conclusion. Good clinical outcome requires achieving
proper spinopelvic alignment in the treatment of adult
spinal deformity. Although variations in pelvic morphol-
ogy exist, a framework has been established to determine
ideal values for regional and global parameter in an indi-
vidualized patient approach. When planning realignment
surgery for adult spinal deformity, restoring low sagittal
vertical axis and pelvic tilt values are critical goals, and
should be combined with proportional lumbar lordosis to
pelvic incidence.
Key words: adult spinal deformity, alignment, pelvic
tilt, lumbar lordosis, realignment surgery. Spine 2010;35:
2224 –2231
The Importance of Alignment
In the domain of spinal surgery, it is useful to recall
important concepts that can serve as a foundation to
understanding and treating deformity. Optimal align-
From the NYU Hospital for Joint Diseases, New York, NY.
Acknowledgment date: November 5, 2009. Acceptance date: June 23,
2010.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to Virginie Lafage, PhD,
NYU Hospital for Joint Diseases, 380 2nd Ave, Suite 1001, New York,
NY 10010; E-mail: virginie.lafage@gmail.com
2224
ment of bone structures and joints is critical for the effi-
cient function of the musculoskeletal system. Further-
more, a complex interaction of the neurologic system
and muscular recruitment is necessary for ergonomic
balance and deliberate displacement of the human body.
Therefore, it is important to consider that ideal spinal
alignment allows an individual to assume standing pos-
ture with minimal muscular energy expenditure. Physio-
logic curvatures of the spine in the sagittal plane, the
straight spine in the coronal plane, balanced tension of
the spinal ligaments, and activation of intrinsic anterior
and posterior musculature should permit extended pain-
free erect position. This concept is reflected in the “Cone
of Economy” principle conceptualized by Jean Dubous-
set1 (Figure 1). Within the center of the cone, the indi-
vidual may remain in an ergonomically favorable erect
position. However, larger deviations in the anterior-
posterior or lateral plane will require greater energy use
to maintain a standing position. Finally, progression out-
side of the “stable cone” results in a loss of postural
control and the need for external supports.
In the setting of adult spinal deformity (ASD), struc-
tural or iatrogenic modifications to spinal alignment
should be considered in perspective of the principles out-
lined previously. Spinal malalignment in ASD challenges
balance mechanisms used for maintenance of an upright
posture to achieve the basic human needs of preserving
level visual gaze and retaining the head over the pelvis.
Progressive severity in skeletal malalignment might re-
sult in greater recruitment in muscular effort and greater
energy expenditure to maintain the erect posture as well
as use of compensatory mechanisms. Spinal malalign-
ment to the extremes of the “Cone of Economy” leads to
extreme muscular demand, fatigue, and significant pain
as well as disability. Once a spinal deformity has reached
the level of marked loss in function and quality of life,
surgical intervention is often recommended and re-
quested.
This article aims to outline the basic principles in the
evaluation and treatment of ASD patients with a focus
on goals to achieve during surgical realignment surgery.
The parameters used for radiographic evaluation and a
review of the clinical evidence to support their attention
are presented. Principles of surgical spinal realignment
with consideration to a pragmatic patient-specific ap-
proach are offered in the form of case presentations. It
will be underlined that while surgical planning may
 ASD–Postoperative Standing Imbalance • Schwab et al 2225

basic understanding of the normative values that these

parameters should fall within (Table 1) . However, since
the work by Vidal and Marnay,10 –11 several authors
have enhanced the understanding of global alignment by
including the pelvis, which has been described as a reg-
ulator of sagittal plane alignment. Numerous studies
have been conducted to understand the relationship be-
tween pelvic parameters and spinal alignment. This has
led to the recognition that pelvic morphology and posi-
tion (Figure 3) are essential components of standing
alignment9,12–15 (Table 1); their clinical relevance is
briefly summarized hereafter:
● Pelvic tilt (PT) is defined by the angle between the
vertical and the line through the midpoint of the
sacral plate to femoral head axis, it is commonly
reported as a compensatory mechanisms: when the
trunk inclines anteriorly (e.g., age related change,
sagittal imbalance, loss of lordosis, increase of ky-
phosis) a subject will try his/her best to maintain an
Figure 1. Cone of balance or cone of economy. The figure outlines
the “stable” zone surrounding the individual that is conical in economic posture and keep the spine balanced (i.e.,
shape from the feet to the head. Deviation from the center within bring the spine over the pelvis). One way to main-
the zone results in greater muscular effort and energy expenditure tain this spinopelvic alignment is to retrovert the
to maintain an upright posture. Deviation of the body outside the pelvis (increase of PT), which might be seen as a
cone results in falling or requiring support. backward rotation of the pelvis around the hips.
● Pelvic incidence (PI) is defined as the angle between
strive for “ideal” alignment, patient factors and external the perpendicular to the upper sacral endplate at its
limiters may require compromises and form an ongoing midpoint and the line connecting this point to the
individualized debate on “how much can you tolerate?” femoral head axis. This is a morphologic parameter
of primary importance commonly used to define
Critical Radiographic Spinopelvic Parameters
spinopelvic morphotypes, or the necessary lumbar
Many clinicians have investigated regional and global alignment under optimal conditions.
spinal alignment in the normal (asymptomatic) adult ● Finally, the sacral slope is defined as the angle be-
population2–9 (Figure 2). These data have provided a tween the horizontal and the upper sacral endplate,

Figure 2. Sagittal spinal radio-

logic parameters. Thoracic ky-
phosis measured from the supe-
rior endplate of T4 to the inferior
endplate of T12. Lumbar lordosis
measured from the superior end-
plate of L1 to the superior end-
plate of S1. SVA defined as the
horizontal offset from the pos-
tero-superior corner of S1 to the
vertebral midbody of C7. T1 Spi-
nopelvic Inclination and T9 Spi-
nopelvic Inclination defined as
the angle between the vertical
plumbline and the line drawn
from the vertebral body center of
T1 or T9 and the center of the
bicoxofemoral axis.
2226 Spine • Volume 35 • Number 25 • 2010

Table 1. Normative Radiographic Spinopelvic Values

Normative Values and References

Schwab et al, Berthonnaud et al, Vialle et al, Legaye et al, Boulay et al, Roussouly
Parameter 20069 20054 200515 199813 200620 200624

No. subjects 75 160 300 49 149 153

Age 49.3 yr (18–80) 25.7 ⫾ 5.5 yr (20–70) 35 yr (20–70) 24.0 ⫾ 5.8 yr (19–50) 30.8 ⫾ 6.0 yr (19–50) 27 yr (18–48)
M:F ratio 0.56 0.95 0.63 0.56 0.52 0.52
SVA ⫺20 ⫾ 30 — — — — 35.2 ⫾ 19.4 (⫺18.1–80.8)
T1-SPI — — ⫺1.4 ⫾ 2.7 (⫺9.2–7.1) — — —
TK (T4–T12) 41 ⫾ 12 47.5 ⫾ 4.8 (22.5–70.3) 40.6 ⫾ 10.0 (0–69) ⬃43.0 ⫾ 13.0 53.8 ⫾ 10.1 (33.2–83.5) 46.3 ⫾ 9.5 (23.0–65.9)
LL (L1–S1) 60 ⫾ 12 42.7 ⫾ 5.4 (16–71.9) 60.2 ⫾ 10.3 (30–89) ⬃60.0 ⫾ 10.0 66.4 ⫾ 9.5 (44.8–87.2) 61.2 ⫾ 9.4 (39.9–83.7)
PI 52 ⫾ 10 51 ⫾ 5.3 (33.7–83.7) 54.7 ⫾ 10.6 (33–82) ⬃52.0 ⫾ 10.0 53.1 ⫾ 9.0 (33.7–77.5) 50.6 ⫾ 10.2 (27.9–82.8)
PT 15 ⫾ 7 12.1 ⫾ 3.2 (⫺5.1–30.5) 13.2 ⫾ 6.1 (⫺4.5–27) ⬃11.0 ⫾ 5.5 12.0 ⫾ 6.4 (⫺2–30) 11.1 ⫾ 5.9 (⫺2.8–23.7)
SS 30 ⫾ 9 39.7 ⫾ 4.1 (21.2–65.9) 41.2 ⫾ 8.4 (17–63) ⬃40.0 ⫾ 8.5 41.2 ⫾ 7.0 (0.6–19.7) 39.6 ⫾ 7.6 (17.5–63.4)
SVA indicates sagittal vertical axis; T1-SPI, T1-Spinopelvic inclination; TK, thoracic kyphosis; LL, lumbar lordosis; PI, pelvic incidence; PT, pelvic tilt; SS, sacral slope.

this last parameter completes the geometrical rela-
tionship where “Pelvic Incidence ⫽ Pelvic Tilt ⫹
Sacral Slope.” Normative values and age-related
changes of the pelvic parameters are provided in
Table 1.
In clinical practice, radiographic reference values help
identify regional angulations and linear displacements
that can be considered as within the normal alignment
range for a given patient. However, because of the large
range considered “normal,” regional values alone are
insufficient in assessing patient-specific harmonious
alignment and the optimal values to strive for in realign-
ing a deformity. It is thus important to consider the idea
of spinopelvic harmony, which relates to the proportion-
ality of one given regional parameter to another and in
practical terms the global spinopelvic alignment of the
individual. In a simplified manner, for a given subject, a
ground rule of harmonious alignment consists of a lum-
bar lordosis (LL) proportional to PI while the thoracic
kyphosis (TK) is proportional to the LL (to a lesser ex-
tent). By a chain of interconnected parameters,4,9,15 spi-
nopelvic harmony implies that focal and regional align-
ment is in proportion to pelvic morphology resulting in a
sagittal vertical axis (SVA), or T1-spinopelvic inclination
(T1-SPI), and PT within a narrow range. When pathol-
ogy, such as ASD perturbs regional alignment, it leads to
a chain of modifications along the standing axis. In se-
vere cases, the consequence is a large SVA/T1-SPI and
PT, lost LL resulting in “spinopelvic mismatch” and re-
sultant loss of function and disability.
Clinical Impact of Spinopelvic Alignment
on Pain/Disability
Various etiologies are tied to spinopelvic malalignment;
however, degenerative and iatrogenic causes comprise
the majority of cases. It should be noted, however, that
whatever the underlying pathology in a patient suffering
from ASD, the correlation between radiographic pa-
rameters and self-reported pain and disability (Health
Related Quality of Life (HRQL) tools) is now well-
defined. Schwab et al,16 in the first series of radio-
graphic analysis, demonstrated the following: end-
plate obliquity of L3/L4, olisthesis, LL; and
thoracolumbar kyphosis were significantly correlated
with self-reported pain assessed using the visual ana-
log scale. These correlations were again confirmed in a
follow-up study17 of 947 ASD patients using disease-
specific validated self reported HRQL instruments in-
cluding the Oswestry Disability Index (ODI) and Sco-
liosis Research Society questionnaire. Increasing
subluxation and progressive loss in LL resulted in
worse outcomes scores and greater self reported pain
and disability.
In a review of 352 ASD patients, Glassman et al18
studied the effect of SVA on HRQL measures. Patients
with and without previous arthrodesis were included in

Figure 3. Pelvic parameters. Pel-

vic tilt defined by the angle be-
tween the vertical and the line
through the midpoint of the upper
sacral endplate to femoral heads
axis (retroversion is then mea-
sured as a PT increase, anterver-
sion as a PT decreases). Sacral
slope defined as the angle be-
tween the horizontal and the up-
per sacral endplate. Pelvic Inci-
dence defined as the angle between the perpendicular to the upper sacral endplate at its midpoint and the line connecting this point to
the femoral head axis. “Pelvic Incidence ⫽ Pelvic Tilt ⫹ Sacral Slope.”

Figure 4. For a given structural deformity, how pelvic retroversion
compensates for spinal deformity. Left, No pelvic retroversion and
high SVA. Middle, Moderate pelvic retroversion and SVA. Right,
high pelvic retroversion and no SVA.
the analysis. Results demonstrate adverse HRQL scores
were significantly correlated with increasing positive
SVA. Finally, in a recent report by Lafage et al,19 coronal
and sagittal radiographs of 125 ASD patients with and
without previous arthrodesis were analyzed for ⬎100
spinal and pelvic parameters. The analysis intended to
prioritize the parameters most correlated to HRQL mea-
sures (including the pelvis) using the ODI, Scoliosis Re-
search Society questionnaire, and SF-12. Results re-
vealed that T1-SPI, a relatively underutilized global
spinopelvic parameter, held the strongest correlation
with each outcome measure. SVA, the more accepted
measure of global spinal alignment, held the second
strongest correlation, whereas PT rounded out the top 3
parameters. Although frequently overlooked, increasing
PT, or pelvic retroversion during standing posture is re-
flective of the patients need to compensate for their prox-
imal spinal deformity (Figure 4). In simple terms, during
progressive positive sagittal spinal malalignment, the
pelvis rotates backward (retroverts) around the hip joint
to offset the effect of sagittal spinal displacement. This
pelvic compensatory mechanism attempts to maintain
level visual gaze and the center the head over the pelvis in
the sagittal plane (center of mass over feet). However, the
compensatory reserve of patients might vary widely,
with some patients exhibiting large pelvic retroversion
reserve and some with very little (possibly related to hip
joint stiffness, muscular issues).
The previously referenced studies delineate the radio-
graphic parameters most correlated with self-reported
pain and disability in the setting of ASD. Interestingly,
the frequently used coronal Cobb angle measure lacks
correlation to HRQL measures in the above referenced
studies. Malalignment in the sagittal plane results in the
disability most consistently expressed in ASD patients. In
addition, correlation of PT with HRQOL measures un-
ASD–Postoperative Standing Imbalance • Schwab et al 2227
derlines the importance of evaluating pelvic parameters
during treatment consideration.
Principles and Pragmatic approach to
Spinopelvic Realignment
Spinopelvic realignment is a complex undertaking.
Other than decompression and stabilization of spinal
segments (which is out of the scope of this report), re-
alignment of the sagittal spinopelvic axis is of primary
importance during surgical treatment of symptomatic
ASD. As outlined earlier, work in the asymptomatic pop-
ulation might provide some insight into the normal
ranges for regional and global alignment during standing
posture. However, for optimal clinical outcomes, treat-
ment should be adapted to a given individual on the basis
of their respective realignment needs. Tailoring patient-
specific treatment involves the crucial PI-LL relationship
previous outlined. Additionally, alignment parameters
driving pain and disability, namely, SVA/T1-SPI and PT,
need to be addressed. The method of realignment,
whether pedicle subtraction osteotomy (PSO), Smith-
Peterson osteotomy, intervertebral spacer, or rod con-
touring is of secondary importance to the primary goal of
obtaining surgical realignment objectives.
Balance formulas in the setting of standing posture are
becoming useful aids for the spine surgeon during com-
plex realignment procedures. However, as a general con-
cept and pragmatic tool for clinical application, spi-
nopelvic realignment objectives involve attention to the
following key parameters (Figure 5).
SVA/T1-SPI
Global spinal realignment should attempt to obtain a
postoperative SVA ⬍50 mm. Restoration of SVA facili-
tates level gaze and achievement of a physiologic stand-
ing posture. An SVA ⬍50 mm brings the C7 plumbline
behind the femoral heads to relieve the complaint of
“falling forward.” Clinically, this threshold has been met
with better HRQL scores. Similarly, the reference T1-SPI
⬍0° might be used. Both parameters refer to truncal in-
clination referenced to the pelvis.
Figure 5. Realignment objectives in the sagittal plane. SVA ⬍50
mm, PT ⬍20°, and LL ⫽ PI ⫾ 9° sets the stage for achievement of
a successful harmonious spinopelvic realignment.
2228 Spine • Volume 35 • Number 25 • 2010
Table 2. Data From a 125 Patient Retrospective Review
of Clinical Outcomes Correlated With Clinically Relevant
Radiographic Values for 3 Key Parameters
SVA PT ⬎20
⬎50 ⬍50 ⬎20 ⬍20
Mean radiographic 134.9 1.7 31.8 10.0
parameter value
Mean ODI scores 42.5 28.4 38.7 29.1
Unpaired t tests ⬍0.001 0.012
on ODI scores
ODI indicates Oswestry Disability Index.
PT
Pelvic realignment should attempt to obtain a postoper-
ative PT ⬍20°. Attention to PT, as outlined by clinical
data, is necessary to obtain optimal outcomes. In addi-
tion, PT realignment restores appropriate femoral-
pelvic-spinal alignment required during efficient ambula-
tion (need an extension reserve to clear the step).
Realignment of the SVA ⬍50 mm in the setting of an
elevated PT means the ASD patient is still compensating
for residual structural spinal deformity. This parameter
independently has been shown to correlate to impair-
ment in walking tolerance; therefore, should be realigned
appropriately.
LL ⴝ PI ⴞ 9°
Finally, to achieve patient-specific alignment treatment
LL ⫽ PI ⫾ 9° may pragmatically be used. Increasing the
angulation of the hypolordotic spine to match the pa-
tient’s spinopelvic morphotype (i.e., PI) assures appro-
priate lordotic alignment. This chain of correlation has
been extensively studied by many authors.9,12,14,20 –21
To identify clinically relevant cutoff values for these
parameters, a retrospective study was carried out on 125
adults with spinal deformity (mean age, 57 years). Ra-
diographic parameters were collected and correlations
with clinical outcomes (HRQL) were investigated.19
When subdivided these patients according to the cutoffs
Figure 6. Pre-post images.
Precoronal (A) and sagittal (B)
radiographs. Post-PSO Realign-
ment, coronal (C), and sagittal
(D) images.
presented in the “alignment objective section,” signifi-
cant differences were noted in terms of ODI using an
unpaired t test (Table 2). Attention to these 3 pragmatic
parameters during surgical intervention sets the stage for
PI–LL
achievement of a successful patient-specific spinopelvic
Greater realignment in the sagittal plane.
⬎9 LL or ⬍9 It is evident that the goals of ideal spinopelvic align-
⫺28.9 17.3 ment cannot be obtained in all cases. Limitations on the
basis of patient factors (e.g., Comorbidities), surgeon
41.8 26.4 factors (experience), operative parameters (e.g., hemo-
⬍0.001
dynamic instability, loss of monitoring potentials), and
constraints of the healthcare environment (ability to
properly care for patients after complex reconstruction)
all need heavy consideration in ambitious operative
planning.
Principles Established, Clinical Application
(Case Studies)
The following section is organized around case presen-
tations and aims to provide an overview on how the
principles outlined previously can be applied in clinical
practice when planning operative spinal realignment
procedures.
Degenerative Deformity: Fusion With
Fixed Malalignment
The radiographs in Figure 6A, B are of a patient with
degenerative lumbar scoliosis and previous anterior-
posterior fusion distally to L5. The major pathology is
global with regional malalignment in the lumbar spine.
By looking at the preoperative values in Table 3 and the
alignment objectives established, one can note that atten-
tion should be directed to all 3 key parameters. Regard-
ing spinopelvic alignment, the patient has the unhappy
trio of high SVA and PT and low LL. The SVA and PT
need to be reduced through realignment while the LL
needs to be increased to PI ⫾9°. Surgical realignment
consisted of a PSO at L2 and aggressive segmental os-
teotomies in the lumbar spine to increase the lordosis.
The fusion was extended to the sacrum and pelvic fixa-
 ASD–Postoperative Standing Imbalance • Schwab et al 2229

Table 3. Pre–Post Radiographic Values: Case 1 Table 4. Pre–Post Radiographic Values: Case 2
Case 1 Case 2

Radiographic Alignment Radiographic Alignment

Parameter Preoperative Objectives Postoperative Parameter Preoperative Objectives Postoperative

SVA (mm) 122.3 ⬍50 mm 28.5 SVA (mm) 106.1 ⬍50 mm 26.5
TK (T4–T12) 56 — 55 TK (T4–T12) 44 — 52
LL (L1–S1) 15 LL ⬃ 41 ⫾ 10 51 LL (L1–S1) 26 LL ⬃ 33 ⫾ 10 47
PI 41 — 43 PI 33 — 33
PT 35 ⬍25 22 PT 14 — 13
SS 6 — 21 SS 19 — 20
SVA indicates sagittal vertical axis; TK, thoracic kyphosis; LL, lumbar lordosis; SVA indicates sagittal vertical axis; TK, thoracic kyphosis; LL, lumbar lordosis;
PI, pelvic incidence; PT, pelvic tilt; SS, sacral slope. PI, pelvic incidence; PT, pelvic tilt; SS, sacral slope.

tion was used for added stability of the long construct.
Two-year postoperative images (Figures 6C, D) demon-
strate restoration of spinopelvic harmony with achieve-
ment of alignment objectives.
Harrington Rod to the Lower Lumbar Spine.
PI–LL Mismatch
Radiographs in Figures 7A, B reveal a common post-
Harrington instrumentation “flatback” deformity.
However, some lordosis remains at the L4 –L5 and L5–S
intervertebral spaces. A mild LL–PI mismatch is evident.
Globally, the patient is shifted forward (Table 4) al-
though without significant pelvic retroversion. The SVA
and PI–LL mismatch are the parameters of importance in
this case. Surgical realignment included a PSO at L3,
with a L5-S TLIF and extension to the pelvis for struc-
tural support. Alignment objectives were obtained with
this patient with a satisfactory overall global alignment
(Figures 7C, D).
Degenerative Disc Disease With Failure of
Prior Instrumentation
Radiographs in Figures 8A, B demonstrate a kyphotic
lumbar spine, failed instrumentation, high SVA, PT, and
moderate coronal malalignment. The goals in realign-
ment need to focus on regional establishment of proper
lordosis, which in turn can rebalance the spine and reset
the pelvis to normal version. Surgical realignment in-
cluded a PSO at L4 with a short fusion from L2 to the
sacrum. Postoperative SVA and PT were substantially
reduced along with an increase in LL (Figures 8C, D,
Table 5).
How Much Can You Tolerate?
The data from studies examining the relationship be-
tween radiographic parameters and HRQL outcomes
demonstrate a considerably strong, linear correlation
between HRQL outcomes, and SVA offset18 and PT.19
Because of this relationship, it is difficult to character-
ize a specific threshold at which point a radiographic
parameter can be considered as conclusively tolerable.
Consequently, the question of what can be tolerated is
rather rhetorical. Ideally, there are normal radio-
graphic ranges and individualized relationships (LL
vs. PI) that serve as targets in planning and performing
surgeries. Nevertheless, even partial improvement in
these parameters is very likely to translate into clinical
benefits. Given this, pursuing surgery becomes a ques-
tion of risk versus benefit.

Figure 7. Pre-post images of a

post-Harrington rod correction
into the lower lumbar spine. Pre-
coronal (A) and sagittal (B) radio-
graphs. Post-PSO Realignment,
coronal (C), and sagittal (D) im-
ages.
2230 Spine • Volume 35 • Number 25 • 2010
Figure 8. Pre-post images of a
short-segment PSO and fusion of
the lower lumbar spine. Precoro-
nal (A) and sagittal (B) radio-
graphs. Post-PSO realignment,
coronal (C), and sagittal (D) im-
ages.
This risk-benefit balance is an individualized consid-
eration. Patient parameters, such as age, overall health,
and bone quality; surgeon parameters, such as skill and
experience; and surgical procedure parameters, such as
technical difficulty and operative time, all factor into the
equation. Studies have attempted to identify specific risk
factors, and ASA score, comorbidities, and primary ver-
sus revision status have all been reported as risk fac-
tors.22 A recent multicenter study has delved into this
further, identifying staging and anterior versus posterior
approaches as significant risk factors.23
The answer to the question, “how much can you tol-
erate,” is not a simple one. It is one that must be an-
swered on an individual patient basis, and depends on
how much benefit can safely be achieved with a reason-
able risk versus benefit balance.
Conclusion
ASD can present with a wide range of clinical symptoms
and radiographic findings. Recent work has identified
key structural parameters to consider in the evaluation
and treatment of ASD. In addition to the clinical affect of
spinal and pelvic parameters, recognition of the interre-
lationship and necessary harmony between values is crit-
ical to optimize individualized treatment.
Some of the guiding principles to ASD treatment have
been outlined in this review. In addition to SVA or T1-
Table 5. Pre–Post Radiographic Values: Case 3
Case 3
Radiographic Alignment
Parameter Preoperative Objectives
SVA (mm) 110 ⬍50 mm
TK (T4–T12) 30 — 34
LL (L1–S1) ⫺2 LL ⬃ 43 ⫾ 10
PI 43 — 42
PT 36 ⬍25
SS 7 —
SVA indicates sagittal vertical axis; TK, thoracic kyphosis; LL, lumbar lordosis;
PI, pelvic incidence; PT, pelvic tilt; SS, sacral slope.
SPI, the PT and PI remain key considerations and permit
a framework to a pragmatic approach for the analysis of
spinal deformity. Through case examples, the direct ap-
plication of principles is offered. It should be noted that
the complexity of standing alignment and deformity
leaves much work to be done. The ongoing HRQOL
analyses and longitudinal studies will certainly refine
balance formulas and guidelines for the treatment of
ASD. In the interim, surgical planning should strive for
ideal alignment while being tempered by risk factors and
limitations in the patient’s healthcare environment. The
question of “how much can you tolerate” cannot meet
with definitive answers but requires ambition to be bal-
anced with good clinical judgment. Ongoing clinical out-
come studies are certain to offer useful algorithms in the
near future.
Key Points
● ASD is a complex interaction between structural
deformity and compensatory mechanisms.
● Correlation between quality of life instruments
and radiographic parameters highlighted the im-
portance of global sagittal balance and pelvic ret-
roversion.
● Harmony among spinopelvic parameters is of
primary importance.
● Realignment objectives should be patient-
specific and involve attention to the following 3
parameters:
• SVA less than 5 cm.
• PT less than 25°.
Postoperative • LL proportional to the PI.
40
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