Spinal Unit , Tripode , Bordeaux , FRANCE

SAGITTAL BALANCE &SURGICAL SPINAL DISORDERS

J. M. VITAL

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DURING

LUMBAR

VERTEBRA »

SPINE

« PELVIC

PELVIC INCIDENCE

M:52°

DUVAL-BEAUPERE

DYNAMIC STATIC

PELVIC VERSION

Mean : 12°

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Mean : 11°

SAGITTAL LIST

IN T9QuickTime™ et un

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FEMORO TIBIAL ANGLE

O

Normal: 0°

ITOI

C7 PLUMBLINE

EAC-FH DISTANCE

« CRANIAL VERTEBRA »

3 SAGITTAL POSITIONS

B

FULL SPINE

FULL LIMBS

« NATURAL POSITION »

« CORRECTED POSITION »

PREOP POSTOP

Peng L, Cooke MS. Fifteen-year reproducibility of natural head posture: A longitudinal study. Am J Orthod Dentofacial Orthop

1999;116:82-5.

Solow B, Tallgren A. Natural head position in standing subjects. Acta Odontol Scand 1971;29:591-607.

Gravity plateformGravity plateform

STEREORADIOGRAPHYSTEREORADIOGRAPHY

External Auditive Duct projection /

Femoral Head centers

CHARPAK

BALANCE

IDEAL OR ECONOMIC

BALANCECOMPENSATED

by

Pelvic Retroversion

+Knees Flexion

ANTERIOR IMBALANCE

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GAIT ANALYSIS

SPINE 2001

+ 6 MONTHS�

2. SPINAL DISORDERS

DEGENERATIVE KYPHOSIS

SPONDYLOLISTHESIS

OSTEOTOMIES in P.O. FLAT BACK

2.1.DEGENERATIVE KYPHOSIS

25 CASES

P.I.:56°

P.V.:29°

T.K.:38°

L.L. :36°

15°

12°

10°

PROFESSIONNAL FACTORS:12/25

TAKEMITSU,1988

HADAR (1989)

FAT DEGENERATION

HADAR 2

HADAR 3

THORACOLUMBAR A

ISOCINETISM 60°/sec.

TRUNK EXT.

TRUNK FLEX

PSOAS/GLUTEUS MAX.

QUADRICEPS/ISCHIO-TIBIALIS

SERIES(10

CASES)

NORMAL SUBJECTSMean age : 30 Y.O.

Ratio Spine Flexors Spine Extensors

63 % 149 % S

Ratio Psoas Gluteus maximus

110 % 63 % S

Ratio Ischio-jambiers Quadriceps

56 % 71 % NS

149% 63%

11O% 6O%

56% 71%

ARTHROGENIC KYPHOSIS : 10 CASES

2.2.SPONDYLOLISTHESIS

• DYSPLASTIC or CONGENITAL SPL• ISTHMIC LYTIC SPL• DEGENERATIVE SPL• TRAUMATIC SPL• TUMORAL SPL• IATROGENIC SPL

SPONDYLOLISTHESIS CLASSIFICATION(MARCHETTI , 1997)

INCIDENCE

(MANGIONE,ROUSSOULY)

PELVIC SHAPE

PELVIC POSITION

- PELVIC VERSION

- LOMBOSACRAL KYPHOSIS

LOMBOSACRAL ANGLE(BRADFORD,DUBOUSSET)

More than 90°

PELVIC TILTINCREASING

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TRUNK POSITION

- T9 SAGITTAL LIST

- THORACIC KYPHOSIS

- LUMBAR LORDOSIS

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SURGICAL TREATMENT of SEVERE DYSPLASTIC SPL

FIRST : ANTERIOR ARTHRODESIS

SECOND : POSTERIEUR ARTHRODESIS

LOMBOSACRAL ANGLE

2. HOW TO PREVENT ?

SAGITTAL IMBALANCE

INTRAOPERATIVE POSITION

MUSCULAR LESIONS

INSTRUMENTATION

POSTERIOR SURGERY

P.O. FLAT BACK

I.O. POSITION

standing seated

POSITION STANDING / SEATED / 4 PADS / G. P.

41°

48°

2°

5°

4 pads G.P.

36°

32°

0°

6°

GENU PECTORAL SEATED 4 PADS STANDING

MUSCULAR LESIONS�

2. TREATMENT

SAGITTAL IMBALANCE

LUMBAR POSTERIOR ( PETERSEN)

LUMBAR PEDICLE SUBSTRACTION

PELVIC

LUMBAR MULTILEVEL POSTERIOR

(CLOSE WEDGING , EGG SHELL)

2.3. SPINAL OSTEOTOMIESin POSTOPERATIVE FLAT BACK

LENKE , J.B.J.S. , 2004

MULTILEVEL POST. O.+/-DISCAL RELEASE+/- CAGES

TRANSPEDICULAR O. (TPO)

VERTEBRAL RESECTION

PREOPERATIVE CALCULATION

in the LUMBAR OSTEOTOMIES

40° 45°

MAXIMUM ANGLE

LUMBAR PEDICLE SUBSTRACTION

TRACINGS ( MANGIONE )

L3L4

LEVEL ( VAN ROYEN )

ANGLE

L3

T9

VP

1212°°

Vertical after osteotomy

SPINEVIEW

L3

T9

PV=12PV=12°°

1111°°

SL=11SL=11°°

Theoric sagittal list

T9

: osteotomy angle

L3

PV=12PV=12°°

SL=11SL=11°°

Theoric sagittal list to 11°

TECHNIQUE

L3 L3L3

IMPLANTS

TRANSPEDICULAR EVIDEMENT

EGG SHELL

INSTRUMENTAL CLOSURE

REDUCTION by the

MOVEMENTS of the O. TABLE

L3:42°

L4:26°

CASE 1

CASE 2

60°

TRANSPEDICULAR OSTEOTOMY RISKS

• NEUROLOGIC DEFICIT (radicular , transitory))

• BLEEDING

• CSF LEAKAGE

• PSEUDARTHROSIS

• SEPSIS

L3 OSTEOTOMY

SCOLIOSIS WORSENING

8°à10°

TRANSPEDICULAR OSTEO. MULTILEVEL O.

ANTERIOR RELEASE

4 LEVELS POST. OST.

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PRE OPERATIVE WALKING

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POSTOPERATIVE WALKING

T.L.I.F.

PELVIC OSTEOTOMY

WILSON 1969

SEGAL 1971

30°

ANTERIOR & POSTERIOR MULTIOPERATED P.

LEFT OSTEOTOMY

GRAFT

PREOP

CONCLUSIONS (1)

to EVALUATE SAGITTAL BALANCEyou must consider

SHAPE & POSITION of PELVIS

POSITION of HIPS and KNEES +++

ARTHROGENIC KYPHOSIS

there is ASSOCIATION with

OSTEOARTICULARMUSCULAR LESIONS

CONCLUSIONS (2)

CONCLUSIONS (3)

SPONDYLOLISTHESIS

ISTHMIC LYSIS is correlated with HIGH INCIDENCE

LUMBOSACRAL KYPHOSIS (L.S.K.) is more PEJORATIVE than SLIPPAGE

SURGICAL CORRECTION of the L.S.K. can correct the GLOBAL IMBALANCE

CONCLUSIONS (4)

OSTEOTOMIES

TRANSPEDICULAR O. is a good procedure to correct fixed imbalance cases

PREOPERATIVE CALCULATION is mandatory

PELVIC OSTEOTOMY is the last possibility