Intraoperatively predicting postoperative sagittal balance using intraoperative X-rays

This study aimed to assess the correlation of sagittal balance parameters measured intraoperatively, against the gold standard post-operative standing full spine X-ray. A secondary aim was to create a predictive algorithm, that could be used intraoperatively to predict the post-operative balance. 49 patients, who underwent thoracolumbar spinal fusion over a 12-month period were included in this study. Standing full-spine X-rays were obtained both pre and post-surgical fixation. Parallel intraoperative X-rays were taken with the c-arm centred on femoral heads, operative level, S1 and L1. The sagittal parameters pelvic incidence (PI), lumbar lordosis (LL), spino-pelvic mismatch (PI-LL), and sagittal vertical axis were then measured and the correlations statistically analysed. For prone positioned patients the mean LL was 59.9° ± 10.6° intraoperatively (post-fixation) and post-operatively 55.4° ± 10.9° with a mean difference of −4.5° ± 6.1° (p-value < 0.001). For laterally positioned patients the mean LL was 50.9° ± 8.6° intraoperatively and 53.1° ± 10.1° postoperatively for a mean difference of −2.3° ± 6.5° (p-value = 0.117). The linear regression analysis resulted in a predictive algorithm that can be utilised intraoperatively to predict the post-operative standing pelvic mismatch for prone positioned patients. In conclusion, measuring spino-pelvic parameters of sagittal balance intraoperatively can be used to estimate postoperative standing full spine x-ray result. Specifically, in the prone position, the surgeon should aim for intraoperative lordosis that is 4.5° more than the desired post-operative lordosis. The predictive formula provides a direct method to quickly calculate the post-operative pelvic mismatch intraoperatively.