J Korean Neurosurg Soc.  2018 Mar;61(2):167-179. 10.3340/jkns.2017.0404.013.

Restoration of Sagittal Balance in Spinal Deformity Surgery

  • 1Department of Orthopaedic Surgery, Spine Service, Columbia University College of Physicians and Surgeons, New York, NY, USA.
  • 2Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea. hyunsj@snu.ac.kr


The prevalence of patients with adult spinal deformity (ASD) has been reported as high as 68%. ASD often leads to significant pain and disability. Recent emphasis has been placed on sagittal plane balance and restoring normal sagittal alignment with regards to the three dimensional deformity of ASD. Optimal sagittal alignment has been known to increase spinal biomechanical efficiency, reduce energy expenditure by maintaining a stable posture with improved load absorption, influence better bony union, and help to decelerate adjacent segment deterioration. Increasingly positive sagittal imbalance has been shown to correlate with poor functional outcome and poor self-image along with poor psychological function. Compensatory mechanisms attempt to maintain sagittal balance through pelvic rotation, alterations in lumbar lordosis as well as knee and ankle flexion at the cost of increased energy expenditure. Restoring normal spinopelvic alignment is paramount to the treatment of complex spinal deformity with sagittal imbalance. Posterior osteotomies including posterior column osteotomies, pedicle subtraction osteotomies, and posterior vertebral column resection, as well anterior column support are well known to improve sagittal alignment. Understanding of whole spinal alignment and dynamics of spinopelvic alignment is essential to restore sagittal balance while minimizing the risk of developing sagittal decompensation after surgical intervention.


Sagittal plane; Spinal deformity; Alignment; Osteotomy
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