Spinal Balance/Alignment—Clinical Relevance and Biomechanics

2019 ◽  
Vol 141 (7) ◽  
Author(s):  
Anoli Shah ◽  
Justin V. C. Lemans ◽  
Joseph Zavatsky ◽  
Aakash Agarwal ◽  
Moyo C. Kruyt ◽  
...  
Keyword(s):  
Social Interaction ◽  
Sagittal Balance ◽  
Sagittal Plane ◽  
The Body ◽  
Optimal Configuration ◽  
Sacral Slope ◽  
Sagittal Imbalance ◽  
Compensatory Mechanisms ◽  
Spinal Balance ◽  
Spinal Imbalance

In the anatomy of a normal spine, due to the curvatures in various regions, the C7 plumb line (C7PL) passes through the sacrum so that the head is centered over the pelvic-ball and socket hip and ankle joints. A failure to recognize malalignment in the sagittal plane can affect the patient's activity as well as social interaction due to deficient forward gaze. The sagittal balance configuration leads to the body undertaking the least muscular activities as possible necessary to maintain spinal balance. Global sagittal imbalance is energy consuming and often results in painful compensatory mechanisms that in turn negatively influence the patient's quality of life, self-image, and social interaction due to inability to maintain a horizontal gaze. Deformity, scoliosis, kyphosis, trauma, and/or surgery are some ways that this optimal configuration can be disturbed, thus requiring higher muscular activity to maintain posture and balance. Several parameters such as the thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), and hip and leg positions influence the sagittal balance and thus the optimal configuration of spinal alignment. This review examines the clinical and biomechanical aspects of spinal imbalance, and the biomechanics of spinal balance as dictated by deformities—ankylosing spondylitis (AS), scoliosis and kyphosis; surgical corrections—pedicle subtraction osteotomies (PSO), long segment stabilizations, and consequent postural complications like proximal and distal junctional kyphosis. The study of the biomechanics involved in spinal imbalance is relatively new and thus the literature is rather sparse. This review suggests several potential research topics in the area of spinal biomechanics.

scholarly journals Spinopelvic sagittal balance: what does the radiologist need to know?

2020 ◽  
Vol 53 (3) ◽  
pp. 175-184
Author(s):  
Leonor Garbin Savarese ◽  
Rafael Menezes-Reis ◽  
Gustavo Perazzoli Bonugli ◽  
Carlos Fernando Pereira da Silva Herrero ◽  
Helton Luiz Aparecido Defino ◽  
...  
Keyword(s):  
Sagittal Balance ◽  
Sagittal Plane ◽  
Lower Limbs ◽  
Sagittal Imbalance ◽  
Optimal Alignment ◽  
Review Of The Literature ◽  
Spinopelvic Parameters ◽  
Compensatory Mechanisms ◽  
Spinopelvic Alignment ◽  
Sagittal Malalignment

Sagittal balance describes the optimal alignment of the spine in the sagittal plane, resulting from the interaction between the spine and lower limbs, via the pelvis. Understanding sagittal balance has gained importance, especially in the last decade, because sagittal imbalance correlates directly with disability and pain. Diseases that alter that balance cause sagittal malalignment and may trigger compensatory mechanisms. Certain radiographic parameters have been shown to be clinically relevant and to correlate with clinical scores in the evaluation of spinopelvic alignment. This article aims to provide a comprehensive review of the literature on the spinopelvic parameters that are most relevant in clinical practice, as well as to describe compensatory mechanisms of the pelvis and lower limbs.

scholarly journals Relationship between hip joint proximity area and sagittal balance parameters: an upright computed tomography study

2020 ◽  
Author(s):  
Shunsuke Kikuchi ◽  
Daisuke Nakashima ◽  
Yoshitake Yamada ◽  
Minoru Yamada ◽  
Yoichi Yokoyama ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Hip Joint ◽  
Sagittal Balance ◽  
Dimensional Space ◽  
Hip Osteoarthritis ◽  
Sacral Slope ◽  
Sagittal Vertical Axis ◽  
Spinal Balance ◽  
Offset Distance ◽  
Sagittal Spinal Alignment

Abstract Purpose A close relationship between sagittal spinal alignment and hip osteoarthritis (OA) has been documented. This study aimed to examine the relationship between hip joint proximity area and sagittal balance parameters in healthy subjects. Methods This prospective study enrolled 47 healthy volunteers who underwent 320-detector row upright computed tomography. Acquired data were reconstructed in a virtual three-dimensional space. The proximity area was determined by < 1 mm of the Hausdorff distance between the acetabulum and the femoral head. Volunteers were divided into the anterior and posterior proximity groups depending on the position of the closest area. Sagittal balance parameters [sagittal vertical axis (SVA), T1 spinopelvic inclination (T1-SPi), T1-pelvic angle, pelvic tilt, sacral slope, pelvic incidence, lumbar lordosis, thoracic kyphosis), offset distance between the centre of the acoustic meati (CAM) and C7 plumb line (CAM-C7-offset), and offset distance between the CAM and hip axis (HA) (CAM-HA-offset)] were compared between the two groups using independent sample t test. Results The anterior proximity group (n = 24) had higher SVA (p = 0.016) and T1-Spi (p = 0.015) than the posterior proximity group (n = 23). CAM-HA-offset was higher in the posterior than in the anterior proximity group (p < 0.000). There was no difference in other parameters (p > 0.05). Conclusion The anterior proximity group had a positive anterior spinal balance; the posterior proximity group may have a more posterior gravity line than the hip joint centre. The anterior spinal balance may contribute to the anterior loading of the hip joint, with known relation with the initiation and onset of hip OA.

Implications of Spinopelvic Alignment for the Spine Surgeon

Neurosurgery ◽  
2011 ◽  
Vol 70 (3) ◽  
pp. 707-721 ◽  
Author(s):  
Vivek A. Mehta ◽  
Anubhav Amin ◽  
Ibrahim Omeis ◽  
Ziya L. Gokaslan ◽  
Oren N. Gottfried
Keyword(s):  
Sagittal Balance ◽  
Lumbar Lordosis ◽  
Pelvic Incidence ◽  
Degenerative Spondylolisthesis ◽  
Disease Process ◽  
Sacral Slope ◽  
Sagittal Imbalance ◽  
Spinopelvic Parameters ◽  
Spinopelvic Alignment ◽  
Spinopelvic Balance

Abstract The relation of the pelvis to the spine has previously been overlooked as a contributor to sagittal balance. However, it is now recognized that spinopelvic alignment is important to maintain an energy-efficient posture in normal and disease states. The pelvis is characterized by an important anatomic landmark, the pelvic incidence (PI). The PI does not change after adolescence, and it directly influences pelvic alignment, including the parameters of pelvic tilt (PT) and sacral slope (SS) (PI = PT 1 SS), overall sagittal spinal balance, and lumbar lordosis. In the setting of an elevated PI, the spineadapts with increased lumbar lordosis. To prevent or limit sagittal imbalance, the spine may also compensate with increased PT or pelvic retroversion to attempt to maintain anupright posture. Abnormal spinopelvic parameters contribute to multiple spinal conditions including isthmic spondylolysis, degenerative spondylolisthesis, deformity, and impact outcome after spinal fusion. Sagittal balance, pelvic incidence, and all spinopelvic parameters are easily and reliably measured on standing, full-spine (lateral) radiographs, and it is essential to accurately assess and measure these sagittal values to understand their potential role in the disease process, and to promote spinopelvic balance at surgery. In this article, we provide a comprehensive review of the literature regarding the implications of abnormal spinopelvic parameters and discuss surgical strategies for correction of sagittal balance. Additionally, the authors rate and critique the quality of the literature cited in a systematic review approach to give the reader an estimate of the veracity of the conclusions reached from these reports.

Implications of Spinopelvic Alignment for the Spine Surgeon

Neurosurgery ◽  
2011 ◽  
Vol 76 (suppl_1) ◽  
pp. S42-S56 ◽  
Author(s):  
Vivek A. Mehta ◽  
Anubhav Amin ◽  
Ibrahim Omeis ◽  
Ziya L. Gokaslan ◽  
Oren N. Gottfried
Keyword(s):  
Sagittal Balance ◽  
Lumbar Lordosis ◽  
Pelvic Incidence ◽  
Degenerative Spondylolisthesis ◽  
Disease Process ◽  
Sacral Slope ◽  
Sagittal Imbalance ◽  
Spinopelvic Parameters ◽  
Spinopelvic Alignment ◽  
Spinopelvic Balance

Abstract The relation of the pelvis to the spine has previously been overlooked as a contributor to sagittal balance. However, it is now recognized that spinopelvic alignment is important to maintain an energy-efficient posture in normal and disease states. The pelvis is characterized by an important anatomic landmark, the pelvic incidence (PI). The PI does not change after adolescence, and it directly influences pelvic alignment, including the parameters of pelvic tilt (PT) and sacral slope (SS) (PI = PT 1 SS), overall sagittal spinal balance, and lumbar lordosis. In the setting of an elevated PI, the spineadapts with increased lumbar lordosis. To prevent or limit sagittal imbalance, the spine may also compensate with increased PT or pelvic retroversion to attempt to maintain anupright posture. Abnormal spinopelvic parameters contribute to multiple spinal conditions including isthmic spondylolysis, degenerative spondylolisthesis, deformity, and impact outcome after spinal fusion. Sagittal balance, pelvic incidence, and all spinopelvic parameters are easily and reliably measured on standing, full-spine (lateral) radiographs, and it is essential to accurately assess and measure these sagittal values to understand their potential role in the disease process, and to promote spinopelvic balance at surgery. In this article, we provide a comprehensive review of the literature regarding the implications of abnormal spinopelvic parameters and discuss surgical strategies for correction of sagittal balance. Additionally, the authors rate and critique the quality of the literature cited in a systematic review approach to give the reader an estimate of the veracity of the conclusions reached from these reports.

scholarly journals Clinical and radiological aspects of the sagittal balance of the spine in children with achondroplasia

2018 ◽  
Vol 6 (4) ◽  
pp. 6-12
Author(s):  
Oksana G. Prudnikova ◽  
Anna M. Aranovich
Keyword(s):  
Sagittal Balance ◽  
Lumbar Lordosis ◽  
Clinical Manifestations ◽  
Pain Syndrome ◽  
Lower Limbs ◽  
Sagittal Imbalance ◽  
Compensatory Mechanisms ◽  
Lateral Instability ◽  
Hip Joints ◽  
Cross Sectional

Background. Changes in the spine with achondroplasia are represented by disorders of synostosis, the presence of wedge-shaped vertebrae, underdevelopment of the sacrum, changes in the size of the roots of the arches, stenosis of the spinal canal, and changes in the sagittal balance. Aim. To investigate the clinical and radiological features of the sagittal balance of the spine in children with achondroplasia. Materials and methods. We performed a cross-sectional clinical and radiological study of 16 patients with achondroplasia aged 6–17 years (mean, 9.2 ± 3.3 years). Radiographically, the parameters of the sagittal balance of the spine and pelvis and scoliosis were evaluated. Clinical evaluation included orthopedic and neurological status and back pain syndrome. Results. The anatomic features of patients with achondroplasia are limb shortening, O-shaped curvature of the lower extremities with lateral instability of the knee joints, and flexural contractures of the hip joints. With restriction of mobility in the hip joints, compensatory mechanisms for correcting sagittal imbalance are triggered: pelvic incline, lumbar lordosis, and thoracic kyphosis change. The clinical manifestations of sagittal imbalance in enrolled children were hypokyphosis of the thoracic spine in 100% and an increase in lumbar lordosis in 56.25% of patients. In 50% of patients, wedge-shaped deformation of vertebral bodies was diagnosed at the level of the thoracolumbar transition with the formation of local kyphosis. Neurological disorders have not been diagnosed in children. Conclusions. The anatomical features of the lower limbs and hip joints in achondroplasia reflect the biomechanical features of the relationship between the spine, pelvis, and lower limbs, which should be considered when planning for orthopedic and spinal surgery after prediction.

Does vertebral level of pedicle subtraction osteotomy correlate with degree of spinopelvic parameter correction?

2011 ◽  
Vol 14 (2) ◽  
pp. 184-191 ◽  
Author(s):  
Virginie Lafage ◽  
Frank Schwab ◽  
Shaleen Vira ◽  
Robert Hart ◽  
Douglas Burton ◽  
...  
Keyword(s):  
Lumbar Lordosis ◽  
Thoracic Kyphosis ◽  
Sagittal Plane ◽  
Pedicle Subtraction Osteotomy ◽  
Sacral Slope ◽  
Spinopelvic Parameters ◽  
Sagittal Vertical Axis ◽  
Significant Difference ◽  
Spinopelvic Parameter ◽  
Spinal Imbalance

Object Pedicle subtraction osteotomy (PSO) is a spinal realignment technique that may be used to correct sagittal spinal imbalance. Theoretically, the level and degree of resection via a PSO should impact the degree of sagittal plane correction in the setting of deformity. However, the quantitative effect of PSO level and focal angular change on postoperative spinopelvic parameters has not been well described. The purpose of this study is to analyze the relationship between the level/degree of PSO and changes in global sagittal balance and spinopelvic parameters. Methods In this multicenter retrospective study, 70 patients (54 women and 16 men) underwent lumbar PSO surgery for spinal imbalance. Preoperative and postoperative free-standing sagittal radiographs were obtained and analyzed by regional curves (lumbar, thoracic, and thoracolumbar), pelvic parameters (pelvic incidence and pelvic tilt [PT]) and global balance (sagittal vertical axis [SVA] and T-1 spinopelvic inclination). Correlations between PSO parameters (level and degree of change in angle between the 2 adjacent vertebrae) and spinopelvic measurements were analyzed. Results Pedicle subtraction osteotomy distribution by level and degree of correction was as follows: L-1 (6 patients, 24°), L-2 (15 patients, 24°), L-3 (29 patients, 25°), and L-4 (20 patients, 22°). There was no significant difference in the focal correction achieved by PSO by level. All patients demonstrated changes in preoperative to postoperative parameters including increased lumbar lordosis (from 20° to 49°, p < 0.001), increased thoracic kyphosis (from 30° to 38°, p < 0.001), decreased SVA and T-1 spinopelvic inclination (from 122 to 34 mm, p < 0.001 and from +3° to −4°, p < 0.001, respectively), and decreased PT (from 31° to 23°, p < 0.001). More caudal PSO was correlated with greater PT reduction (r = −0.410, p < 0.05). No correlation was found between SVA correction and PSO location. The PSO degree was correlated with change in thoracic kyphosis (r = −0.474, p < 0.001), lumbar lordosis (r = 0.667, p < 0.001), sacral slope (r = 0.426, p < 0.001), and PT (r = −0.358, p < 0.005). Conclusions The degree of PSO resection correlates more with spinopelvic parameters (lumbar lordosis, thoracic kyphosis, PT, and sacral slope) than PSO level. More importantly, PSO level impacts postoperative PT correction but not SVA.

scholarly journals Increasing pelvic incidence is associated with more global sagittal imbalance in ankylosing spondylitis with thoracolumbar kyphosis

2019 ◽  
Author(s):  
Diyu Song ◽  
Guoquan Zheng ◽  
Tianhao Wang ◽  
Dengbin Qi ◽  
Yan Wang
Keyword(s):  
Ankylosing Spondylitis ◽  
Sagittal Balance ◽  
Pelvic Incidence ◽  
Pearson Correlation ◽  
Control Group ◽  
Sacral Slope ◽  
Sagittal Imbalance ◽  
Thoracolumbar Kyphosis ◽  
Spinopelvic Parameters ◽  
The Relationship

Abstract Background: Ankylosing spondylitis (AS) patients with kyphosis have an abnormal spinopelvic alignment and pelvic morphology. Most studies focus on the relationship of pelvic tilt (PT) or sacral slope (SS) and deformity, and relatively few studies have addressed the relationship between pelvic incidence (PI) and kyphosis in AS patients. The purpose of this study is to analyze the correlation between pelvic incidence (PI) and the spinopelvic parameters describing local deformity or global sagittal balance in AS patients with thoracolumbar kyphosis. Methods: A total of 94 patients with AS (91 males and 3 females) and 30 controls were reviewed. Sagittal spinopelvic parameters, including PI, PT, SS, thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), lumbar lordosis(LL), sagittal vertical axis(SVA), the first thoracic vertebra pelvic angle(TPA), spinosacral angle(SSA) and spinopelvic angle(SPA) were measured. Pearson correlation (r) and unary linear regression model were used to analysis the relationship between PI and other spinopelvic parameters. Results: Compared with the control group, the AS patients had significantly higher PI(47.4˚ vs. 43.2˚, P<0.001). PI in AS patients was found to be significantly positively correlated with TPA(r=0.533, R2=0.284, P<0.001), and negatively correlated with SPA(r=-0.504, R2=0.254, P<0.001). However, no correlations were found between PI and SVA, SSA, TK, TLK or LL in AS patients. Conclusion: This study revealed that increasing PI was significantly correlated with more global sagittal imbalance, not with the local deformity in AS patients with thoracolumbar kyphosis. Key Words: ankylosing spondylitis, pelvic incidence, sagittal spinopelvic parameters, global sagittal balance

scholarly journals The compensatory mechanisms for global sagittal balance in degenerative spinal kyphosis patients: a radiological analysis of muscle-skeletal associations

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Weiwei Xia ◽  
Weiyan Wang ◽  
Zhenqi Zhu ◽  
Chenjun Liu ◽  
Shuai Xu ◽  
...  
Keyword(s):  
Sagittal Balance ◽  
Psoas Muscle ◽  
Head Position ◽  
Erector Spinae ◽  
Vertical Line ◽  
Sacral Slope ◽  
Compensatory Mechanisms ◽  
Sagittal Vertical Axis ◽  
Pelvic Parameters ◽  
Positive Correlations

Abstract Background The position of the head relative to the spine can be used to evaluate the true global balance in patients with degenerative spinal kyphosis (DSK). However, it is still not clear how the position of the head is related to the spinal-pelvic parameters and lumbar muscles, which are most commonly considered. Methods Sixty-seven patients with DSK admitted in the hospital from January 2017 to January 2019 were retrospectively analyzed. All patients had whole spine X-ray and lumbar MRI. The head position parameters include: the angles of both lines joining the center of acoustic meati (CAM) to the center of the bi-coxofemoral axis (BA) (CAM-BA) and the most superior point of dentiform apophyse of C2 odontoid (OD) to BA (OD-BA) with the vertical line; the distance between the vertical line passing CAM and the posterior upper edge of the S1 (CAM-SVA). The spinal parameters include: C7 sagittal vertical axis (C7-SVA), thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), and lumbar lordosis (LL). The pelvic parameters include: pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS). The relative cross-sectional area (RCSA) of bilateral multifidus, erector spinae and psoas muscle at L3/4 and L4/5 segments were measured. The correlations between head position parameters and the spinal-pelvic parameters and RCSA of lumbar muscles were analyzed, respectively. Results Significant positive correlations were found between each two of CAM-SVA, C7-SVA, CAM-BA and OD-BA (p < 0.001). SS was found to be significantly positively correlated with CAM-BA (r = 0.377, p = 0.034) and OD-BA (r = 0.402, p = 0.023). CAM-BA was found to be significantly negatively correlated with TK (r = − 0.367, p = 0.039). Significant positive correlations were found between RCSA of multifidus at L3/4 level and CAM-SVA (r = 0.413, p = 0.021), CAM-BA (r = 0.412, p = 0.019) and OD-BA (r = 0.366, p = 0.04). Conclusions Our study showed that the head position relative to the spine were significantly correlated to some spinal-pelvic parameters, and the lower lumbar multifidus muscle. The compensatory mechanisms of the global sagittal balance status should also involve the head position area.

scholarly journals The impact of spinopelvic morphology on the short-term outcome of pedicle subtraction osteotomy in 104 patients

2017 ◽  
Vol 27 (1) ◽  
pp. 74-80 ◽  
Author(s):  
Karin Eskilsson ◽  
Deep Sharma ◽  
Christer Johansson ◽  
Rune Hedlund
Keyword(s):  
Clinical Outcome ◽  
Sagittal Plane ◽  
Vertical Axis ◽  
Pedicle Subtraction Osteotomy ◽  
Sacral Slope ◽  
Sagittal Imbalance ◽  
Sagittal Vertical Axis ◽  
Term Outcome ◽  
Pelvic Morphology ◽  
The Impact

OBJECTIVEPedicle subtraction osteotomy (PSO) is commonly performed for correction of spinal sagittal plane deformities. The PSO results in complex, multiple changes of the spinopelvic alignment. The influence of the variability of individual pelvic morphology has not been fully analyzed in previous outcome studies of sagittal imbalance. The aim of this study was to define radiological variables affecting the outcome after PSO in adult spinal deformities, with special emphasis on the variability of pelvic morphology.METHODSClinical and radiographic outcomes were analyzed in a retrospective analysis of 104 patients who underwent a PSO at a single center. The radiographic variables studied were sagittal vertical axis (SVA), T1SPI (T-1 spinopelvic inclination), lumbar lordosis (LL), thoracic kyphosis (TK), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). To control for the individual variation of pelvic morphology, the LL/PI, PT/PI, and SS/PI ratios were calculated. Clinical outcome was assessed using the visual analog scale for pain, Oswestry Disability Index, and EQ-5D preoperatively and at a minimum 1-year follow-up. Correlation coefficients were calculated between each individual radiographic variable and the outcome measures. The importance of LL mismatch to TK, reflecting the importance of a harmonious spine, was analyzed by comparing the outcome of patients with a TK+LL+PI ≤ 45° to those with a sum > 45°.RESULTSSVA and T1SPI demonstrated the strongest correlation with the clinical outcome scores (r = 0.4–0.5, p < 0.001). LL correlated weakly with the clinical outcome (r = 0.2–0.3, p < 0.003). Mismatch of LL to PI, however, did not correlate significantly with the outcome. Similarly, only weak and inconsistent correlation was observed between PT, SS, PT/PI, SS/PI, and functional outcome. Patients with a TK+LL+PI ≤ 45° had a significantly lower ODI score (33 vs 44) and a significantly higher EQ-5D score (0.64 vs 0.40) than patients with a sum > 45° (LL is a negative value).CONCLUSIONSPSO resulted in a substantial correction of sagittal imbalance and improved outcome in most patients in this study. Correction of the global sagittal balance appears to be a necessary precondition for a good outcome. A harmonious spine with a TK and an LL of similar magnitude seems to add to a positive outcome.

Anterior Column Realignment: Analysis of Neurological Risk and Radiographic Outcomes

Neurosurgery ◽  
2020 ◽  
Vol 87 (3) ◽  
pp. E347-E354 ◽  
Author(s):  
Rajiv Saigal ◽  
Behrooz A Akbarnia ◽  
Robert K Eastlack ◽  
Ali Bagheri ◽  
Stacie Tran ◽  
...  
Keyword(s):  
Sagittal Plane ◽  
Anterior Column ◽  
Motor Deficit ◽  
Sacral Slope ◽  
Sagittal Imbalance ◽  
Sagittal Vertical Axis ◽  
Pelvic Inclination ◽  
Radiographic Outcomes ◽  
Neurological Risk

Abstract BACKGROUND Anterior column realignment (ACR) is a less invasive alternative to 3-column osteotomy for the correction of sagittal imbalance. We hypothesized that ACR would correct sagittal imbalance with an acceptable neurological risk. OBJECTIVE To assess long-term neurological and radiographic outcomes after ACR. METHODS Patients ≥18 yr who underwent ACR from 2005 to 2013 were eligible. Standing scoliosis radiographs were studied at preoperation, postoperation (≤6 wk), and at minimum 2 yr of follow-up. Clinical/radiographic data were collected through a retrospective chart review, with thoracic 1 spino-pelvic inclination (T1SPi) used as the angular surrogate for sagittal vertical axis. RESULTS A total of 26 patients had complete data, with a mean follow-up of 2.8 yr (1.8-7.4). Preoperative, sagittal parameters were lumbar lordosis (LL) of −16.1°, pelvic incidence (PI)-LL of 41.7°, T1SPi of 3.6°, and pelvis tilt (PT) of 32.4°. LL improved by 30.6° (P &lt; .001) postoperation. Mean changes in PT (−8.3), sacral slope (8.9), T1SPi (−4.9), and PI-LL (−33.5) were all significant. The motion segment angle improved by 26.6°, from 5.2° to −21.4° (P &lt; .001). Neurological complications occurred in 32% patients postoperation (n = 8; 1 patient with both sensory and motor). New thigh numbness/paresthesia developed in 3 (13%) patients postoperation; only 1 (4%) persisted at latest follow-up. A total of 6 (24%) patients developed a new lower extremity motor deficit postoperation, with 4 (8%) having persistent new weakness at last follow-up. Out of 8 patients with preoperative motor deficit, half saw improvement postoperation and 75% improved by last follow-up. CONCLUSION There was net motor improvement, with 24% of patients improving and 16% having persistent new weakness at latest follow-up; 60% were unchanged. Radiographic results demonstrate that ACR is a useful tool to treat severe sagittal plane deformity.

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